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THE OPERATING ROOM 

A PRIMER FOR PUPIL NURSES 


BY 

AMY ARMOUR SMITH, R. N. 

* * 

FORMERLY SUPERINTENDENT OF NEW ROCHELLE HOSPITAL, NEW 
YORK ; SUPERINTENDENT OF NURSES AT THE S. R. SMITH INFIRMARY, 
STATEN ISLAND, AND AT THE WOMAN’S HOSPITAL OF THE STATE 

OF NEW YORK 


SECOND EDITION, RESET 


* '* * 

> J 3 

% » 

PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 

1924 





■RDss 


Q „ 


I1Z + 


Copyright, 1916, by W. B. Saunders Company. Reprinted 
November, 1918, and January, 1921. Revised, en¬ 
tirely reset, reprinted, and recopyrighted 
September, 1924 


Copyright, 1924, by W. B. Saunders Company 





/ 


9 

■ 



MADE IN U. S. A. 


PRESS OF 

W. B SAUNDERS COMPANY 
PHILADELPHIA 




©Cl A807040 








To 


MISS LUCY ANN MARSHALL, R. N., 


THE BEST ADMINISTRATOR I HAVE YET MET 







INTRODUCTION 


To take the experience and teaching of an active pro¬ 
fessional life and incorporate it within the compass of 
this volume is no small task. To formulate and present 
the background of theory and science of operating- 
room practice is difficult and does not lend itself tb con¬ 
ciseness. The author has written a book for the operating 
room and of the operating room and has set forth clearly 
and distinctly the general principles and the specific 
detailed information that go to educating the nurse to the 
fullest degree in all that pertains to the organization, 
administration, and conduct of an operating room. In 
the ever-widening field of surgical knowledge and the 
closely related specialties of medicine it is opportune that 
there should be collected and printed the last word, so 
to speak, in operating-room technic. In the bewildering 
array of facts to be mastered, technical procedures to be 
learned and the tremendous importance of the preparation 
of everything connected with an operation so that there 
will be no possibility of contamination or soiling we have 
a task that will test the physical and mental capacity of 
the most ambitious young woman desiring to make her¬ 
self proficient in operating-room technic. 

Few surgeons, hospital superintendents, and superin¬ 
tendents of nurses seem to realize the tremendous organ¬ 
ization that is represented in the xi ?rating-room depart¬ 
ments of the modern hospital. Mrs. Smith begins her 
treatise at the operating room itself, and by carefully 
calculated and well presented chapters conducts the 
neophyte through the physical make-up of the operating 
room, the duties that pertain to the various positions of 
circulating nurse, anesthesia nurse, suture nurse, and 

3 



4 


INTRODUCTION 


operating-room supervisor. Large as are these desig¬ 
nated duties there is still a larger domain in operating- 
room pedagogy. The necessity for a thorough knowledge 
of the mechanics of sterilization, the preparation of solu¬ 
tions, and dressings, the maintenance of supplies and 
the disposal of soiled material, furthermore, the enigma 
of surgical nomenclature, the relationship between the 
superintendent of the hospital proper and the supervising 
nurse of the operating room are all important and make 
for success or failure in administration. These are all 
fundamental topics which must be thoroughly mastered 
before one is able to comprehend fully the mental equip¬ 
ment necessary for the proper and efficient maintenance of 
an operating-room pavilion. 

The volume is essentially practical and with its detailed 
instruction is immediately available for the probationer 
as well as the graduate nurse. The author has, however, 
given discursive information about the principles under¬ 
lying the practical application of the precepts which en¬ 
able the reader to understand that larger background 
which must necessarily precede the application of all 
knowledge. 

The members of the medical profession who have been 
identified with hospital committees on the administration 
of operating rooms will appreciate readily the diffi¬ 
culties of transmitting operating-room knowledge to each 
succeeding nurse as she progresses in her hospital rotation 
through various subordinate positions in the operating- 
room department. To administrators in general this book 
should be particularly useful and prove to be a practical 
guide to the nurse beginning her training and who for 
the first time enters the operating room with its tre¬ 
mendous detailed work and finds herself at a loss to un¬ 
derstand the complicated machinery to which she is 
introduced. To the nurse who occupies one of the sub¬ 
ordinate positions in the operating room it will be found 
invaluable to consolidate her information and give it an 
orderly place in her mind. To the graduate nurse oc- 


INTRODUCTION 


5 


cupying a senior position, such as suture nurse, or super¬ 
visor of one of the minor operating rooms, it will be 
a regular vade mecum, with its precise information, its 
admirable illustrations, its charts, and its complete for¬ 
mulary and glossary of technical terms. To the nurse 
occupying the position of supervisor of operating rooms 
it will form the basis of regular systematized lectures and 
provide a comprehensive viewpoint of the whole domain 
of skilled nursing and operating-room administration such 
as is necessary in the conduction of any well-established 
surgical clinic. To the superintendent of nurses and the 
hospital superintendent it should provide a standard 
whereby the derelictions of their own service may be 
evaluated in terms of modern operating-room efficiency. 
It will well repay the surgeon to peruse it that he may 
better appreciate that as the active and professional unit 
in the group he must of necessity co-ordinate his activities 
with all of the associates that contribute to the running, 
the maintenance, and administration of the surgical 
department. 

The desirability of having such information in a con¬ 
cise, well-planned and co-ordinated volume is apparent 
and it is with the greatest personal appreciation of its 
prospective usefulness to the nurse, to the supervisor, and 
to the surgeon that it is presented to the medical public 
and nursing profession at large. 

Charles Gordon Heyd, M. D., 
Professor of Surgery , 

New York Post-Graduate Medical 
School and Hospital. 

116 East 53rd Street, 

New York City. 






FOREWORD TO SECOND EDITION 


The mere acknowledgment of the help received from 
the many surgeons mentioned in the text of this edition, 
whose genius evolved the special features mentioned as 
aids for nurses in operating-room work is far from enough 
to convey the real thanks of the author to them, nor can 
words express the feelings stirred by the warm hospitality 
of her own school, in the New York Post-Graduate Hos¬ 
pital, extended during its compilation, and crowned by 
the generous remarks of one of its brilliant surgeons, Dr. 
Charles Gordon Heyd, by way of introduction. The firms 
whose applied science lent help in the form of electro¬ 
types of up-to-date apparatus, Meinecke & Co., Kny- 
Scheerer Corporation, and others, have contributed in a 
very kind, prompt manner to the possibilities for its use¬ 
fulness. 

Amy Armour Smith. 

New Rochelle, N. Y. 

September , 1924. 7 




















































































































FOREWORD 


This little book has been slowly and anxiously pieced 
together not by one continuous task, but by culling an 
idea here, a formula there, a test somewhere else, from 
the conversations of numerous good friends in the medical 
and nursing professions, and from happy memories of 
days in training under the kindly, thorough instruction of 
Miss A. M. Rykert and Miss J. MacCallum (now Mrs. 
Schenck, of Detroit), for the opportunity to be under 
whom those who were so fortunate have been increasingly 
proud and grateful as time goes by. Yet, withal, this 
book will seem rather crude in comparison with the finished 
work of experienced authors. Generously excuse its 
faults on the ground that it is only a pioneer, from a nurse 
to nurses, and not from a physician to nurses! These data 
have been garnered from journals on nursing, from physi¬ 
cians’ libraries, and from the practical experiences of 
friends. If its humble appearance proves to be an in¬ 
spiration to others more skilled, to take up the labor and 
go farther, it will have accomplished much. If, again, 
any nurse chances to learn that she too can constantly 
acquire information that may be at any time, no matter 
how remote, tremendously useful to her, it will not have 
been written in vain. 

My sincere thanks are due to Dr. T. Mitchell Prudden 
and Dr. W. M. Brickner for permission to quote from 
their valuable works, to Dr. C. A. Smith and Dr. C. H. 
Fulton for their constant personal assistance, to Dr. E. M. 
Smith and Dr. A. Beck for contributions on their special 
lines of work, to Mr. F. H. Kollman for useful pharma¬ 
ceutic data, and to the firms Kny-Scheerer Corporation, 

9 



10 


FOREWORD 


Foregger Co., Inc., Lentz & Sons, for the loan of 
numerous electrotypes, and to J. F. Newman, manufac¬ 
turing jeweller, for the design on the title-page. 

Most especially, however, this work has been forwarded 
and is largely due to the encouragement and careful 
revision given by Miss B. I. Brazeau, R. N., and Miss I. 
M. Hall, R. N., two operating-room nurses, whose abso¬ 
lute conscientiousness, skill, and willing spirit, enhanced 
by many tenderer graces that make the perfect woman, 
deserve a far higher tribute than can here be given. 

“ The Trained Nurse and Hospital Review ” kindly 
gave permission to use the original articles which were 
expanded for some of these chapters. 

Amy Armour Smith. 


New Rochelle, N. Y. 


CONTENTS 


CHAPTER I 

The New Operating-room Pupil. 

Rotation of Service, 17—The First Day, 17—Psychology of 
Training, 18—Surgeon’s Relation to the Novice, 18—Pu¬ 
pil’s Responsibility to the Surgeon, 19—Operating Room 
as Related to the Community, 20—Progress in Methods, 
20—Telephone, 20—Morals of Pupil, 21. 

CHAPTER II 


The Circulating Nurse. 

Her Numerous Duties, 23—Dusting, 23—Learning, 26— 
A Place for Everything and Everything in Its Place, 26— 
Control of Special Conditions, 27—Utensils, 27—Linen, 27 
—Counting of Linen, 28—Building Stretchers, 28—Dress, 
29—Applying Binders, 29—Scrubbing Up, 29—Holding 
Retractors, 30—Setting Up, 30—Regular Duty of Cir¬ 
culating Nurse During Operations, 30—The Engineer as 
Instructor, 35—Changing Cases, 35—General Addenda, 37 
—Summary of Treatments for Shock, Hemorrhage, etc., 39 
—Sponge Count (Pros and Cons), 41—Washing Sponges, 42. 

CHAPTER III 


The Anesthetic Nurse. 

Definition, 43—Instruction, 43—Positions, 44—Methods 
with Tables, 46—Setting Up the Anesthetic Room, 47— 
Needs of the Nurse Anesthetist, 49—Rights of the Patient, 
50—Lifting Patient Skilfully, 53—Problem: Should Nurses 
Administer Anesthetics? 54—Oxygen for Stimulation, 55— 
Special Anesthetics, 57—Spinal, 57—Rectal, 58'—Local, 
58—Cocain, 59—Novocain, 60—Quinin and Urea Hydro- 
chlorid, 60—General History of Anesthesia, 60—Classes of 
Anesthesia, 60—Preparation for General Anesthesia, 60— 
Three Stages, 61—General Addenda, 62—Return of Pa¬ 
tient to Bed, 66—Recovery Room, 66—Murphy Drip, 67 
—Gatch Bed, 68—Lavage, 68—Bladder Drainage, 68. 

11 






12 


CONTENTS 


CHAPTER IV page 

The Suture Nurse. 69 


Problems of the Personnel, 69—Suture Nurse, 70—Con¬ 
ducting an Operating Room, 72—Duties Before Operation, 

73— Preparation of Skin at Operation, 73—Rules for Scrub¬ 
bing Up and Setting Up, 74—Carrying on the Operation, 

74— Change of Surgeon, 76—Records, 76—Specimens, 76— 
Instruments, 76—Ambulance Bags, 78—Supplies Made by 
Pupils, 78—Needles, 79—Sutures, 81—Ligatures, 84— 
Making of Catgut, 85—General Addenda, 85. 

CHAPTER V 

The Operating-room Supervisor. 92 

Her Status: A. National, 92—B. Local, 92—Possible Stand¬ 
ardization of This Office by Boards of Directors, 92—Her 
Relation to Her Community, 93—Competition with Other 
Operating Rooms, 94—Finances of the Suite, 94—Method 
of Applying for Positions, 95—Inbreeding Disastrous to 
Tone, 96—Limits to Her Jurisdiction, 97—Her Personal¬ 
ity, 97—Examinations (Triennial) Held by College of Sur¬ 
geons Desirable to Elevate Tone, 98—Teaching Duties, 99 
—Arithmetic of Drugs, 99—Anatomy, 100—Practical 
Methods by Demonstration, 101—Nursing Care, 101— 
Economy, 102—Wisdom in Buying, 103—Management of 
Repairs, 104—Discipline, 104—Prevention of Infections, 

104—Self-reliance, 105—Inspections, 105—Preparedness, 

106—State Laws, 106—Health of Pupils, 107—Compilation 
of Statistics, 107—Academic View of Work, 108—Sum¬ 
mary, 109 

CHAPTER VI 

The Main Operating Room. Ill 

Planning, 111—Position, 113—Size, 113—Heating, 113— 
Finish, 114—Light, 114—Rules for Keeping Electric Equip¬ 
ment in Order, 116—Corners, 117—Disinfection, 117- 
Doors, 118—Perfect Cleanliness, 119—Plumbing, 120— 
Tables, 121—Stools, 122—Clock, 122—Signals, 122- 
Blackboard, 122—Table Pads, 122—Cautery, 123—Ejector, 

124—Waste Receptacles, 124—Scrub Pails, 125—Irrigat¬ 
ing Tank, 125—Cabinets, 125—Elevators, 125—Flooring, 

126—Summary, 126. 


CHAPTER VII 

Sterilizing Room. 127 

Definition of Sterilization, 127— Methods of Sterilization, 

127— Sources of Heat, 127— Preparations Before Sterilizing, 

128— Protection of the Sterilizing Room, 128— Principles in 
the Architect’s Plan, 134— Equipment, 136— Points to 
Avoid, 142— Engineer’s Instructions, 142—Supervisor’s 






CONTENTS 


13 

PAGE 

Duties, 142—Printed Codes, 143—General Notes, 144- 
Details of Sterilization of Special Materials, 144—Looking 
at the Sterilizing Room from the Outside In, 146—The 
Dressing Sterilizer; Its Effective and Ineffective Use, 146. 

CHAPTER VIII 

Minor Operating Rooms, Workrooms, and Accessories. . . 150 
Reasons for Minor Rooms, 150—Special Rooms for Single 
Types of Surgery, 151—A. “Scopic” Tonsil, 151—B. Eye, 

151—C. Septic, 152—Workroom, 152—Hints on Manage¬ 
ment of Workroom, 154—Hopper Room, 155—Store 
Rooms, 156—Dressing-room for Orderlies, 157—Nurses’ 
Dressing-rooms, 157—Doctors’ Dressing-rooms, 157. 

CHAPTER IX 

Asepsis . 158 

Definition of Asepsis, 158—Preparation of Nurse to Com¬ 
prehend Asepsis, 160—Chart of Germless Journey of Gloves, 
etc., to Patient, 161—Chart of Trails, 161—Chart of Bar¬ 
riers of Safety, 161—Definition of Technic, 170—Break in 
Asepsis, 170—Pins, 171—Preparation of Nurse for Assisting 
at Operation in Private House, 171—Directions for Scrub¬ 
bing Up, 172—General Addenda, 172. 

CHAPTER X 

Formulae and Directions . . 176 

Formula and Preparation of Dakin’s Solution, 176—Prep¬ 
aration of Hypochlorite Solution, 176—Thiersch’s Solution, 

177—Formulae for Iodoform Packing, 177—Catgut, 179— 
Surgeons’ Silk, 179—Silkworm Gut, 179—Bone-wax, 179— 
Aluminum Acetate Solution, 180—Boric Acid Solution, 180 
—Normal Saline, 180—Bichlorid of Mercury Solutions, 182 
—Colors, 184—Tables, Troy, Avoirdupois, Apothecaries’ 
Weight, Apothecaries’ Measure, 184—Symbols, 184—Ab¬ 
breviations, 184—Formaldehyd, 184—Formalin, 185— 
Nitrate of Silver, 185—Percentage Solutions, 185—Ringer’s 
Stock Salt Solution, 186—Harrington’s Solution, 186— 
Bismuth Gauze Drains, 186—Rubber Goods: Tubing, 
Dam, Tissue, Gloves (Buying, Records, Responsibility, 
Arrangement, To Put Up, Mend, Powder, Sterilize), Aprons, 
Hard Black Rubber, Catheters (Plain, Mushroom, and 
T-Retention), 187—Filiforms, 192—Bougies, 193—Silk 
Catheters, 193—Fumigating Cabinet, 193—Preservation of 
Specimens, 193—Care of Glassware, 194—Soda Bicarbon¬ 
ate Solution, 194—Glucose Solution, 194—Silver Leaf, 194 
—How to Prepare Sterile Adhesive, 195—Hooks and Eyes as 
a Substitute for Skin Sutures, 195—Diachylon Plaster, 196 
—Syringes, 196—Care of Tracheotomy Tubes in Situ, 196 
—Care of Instruments, 196—Hospital Cold Cream, 199— 
Hospital Hand Lotion, 199—How to Sterilize Vaseline, 199. 




14 


CONTENTS 


CHAPTER XI page 

Metric System. 201 


Metric Linear Measure, 201—Square Measure, 202—Cubic 
Measure, 203—Volume, 203—Weight, 204—Centigrade 
Thermometers (Clinical and Dairy), 205. 

CHAPTER XII 

Operating-room Pharmacopoeia . 208 

U. S. P., 208—Preservation of Drugs, 208—Safeguarding 
Poisons, 209—Safeguarding Valuable Drugs, 209—Safe¬ 
guarding Narcotics, 209—Moral Responsibility, 210— 
Preservation of Asepsis, 210—Method of Computing Cocain 
Solutions, 210—Method of Computing Hypodermic Dosage, 

211—-Legal Phases, 212. 

CHAPTER XIII 

Dressings . 213 

General Principles, 213—Gauze, 213—A. Sponges, 213—B. 
Mastoid Tips, 215—C. Mastoid Dressing, 215—D. Gant 
Pad, 215—E. Whistle, or Tampon Cannula, 216—F. 
“Canule 4 Chemise,” 216—G. Leg Rolls, 217—H. Stump 
Dressing, 217—I. Eye Pads, 217—J. Vaginal Packing, 217 
—K. Bandages, 217—L. Packing, 217—M. Retractors, 218 
—Cotton, 218—A. Balls, 218—B. Aristol Pledgets, 218—C. 
Applicators (Long Ear), 219—D. Toothpicks (Short Eye), 

219—E. Babies’ (All Cotton, Nostrils), 219—Tampons, 219 
—Linen Bobbinette, 220—Muslin Bandages, 220—Flannel¬ 
ette, 220—Wick, 220—Chiropodists’ Plaster, 220—Cloth 
Retractors, 220—Tape Stickers, 221—T-Binders, 221— 
Ether Cones, 222—Making of Supplies, 222. 

CHAPTER XIV 

Linen of the Operating Room . 223 

Estimation of Stock Required, 223—Linen Chart, 223— 
Whiteners of Linen, 223—Training in Economics, 225— 
Measures, 226—Nurses’ Gowns, 226—Doctors’ Gowns, 226 
—Doctors’ Suits, 226—Shields, 227—Covers, 227—Masks, 
Helmets, Mouthpads, 227—Suspensories, 228—Laparotomy 
Suits, 228—Scultetus Binders, 228—Maternity Breast- 
binder with Sleeve, 230—Caps, 231—Laparotomy Sheets, 

231—Vaginal Sheets and Triangles, 231—Gown Covers, 

231—Covers for Packing Tubes, 231—Dressing-covers, 232 
—Blankets, 232—Flannel Masks, 234—Folding Linen, 234 
—Folding Gowns, 236. 

CHAPTER XV 

Terms Used in Surgical Diagnosis . 237 

Reasons Why Nurse Should Know the Diagnosis, 237— 
Table of Tumors, 238—Cysts, 238—Glossary of Terms, 239. 







CONTENTS 


15 


CHAPTER XVI 

PAGE 

Nomenclature of Operations. 258 

Careful Use of Terms, 258—Model of Slip to Ward, 259— 
Rules for Formation of Terms Naming Operations, 259— 
Roots of Classic Origin: A. Anatomic Part, B. Nature 
of Work Done, 261—Glossary of Terms Made from These 
Roots, 263—Special Verbs Relating to Operating, 265. 


CHAPTER XVII 

List of Instruments for Operations. 267 

Dissecting Set, 267—Nurse’s Set, 267—Decompression, 267 
—Mastoidotomy, 269—Removal of Ossicles of Middle Ear, 

271—Resection of Jugular Vein, 272—Skin-grafting, 273— 
Incision of Brain Abscess, 273—Radical for Infected Frontal 
Sinus, 273—Iridectomy (Partial), 274—Removal of Foreign 
Body in Eye, 276—Strabotomy, 276—Enucleation of Eye, 
277—-Submucous Resection of Nasal Septum, 277—Ade- 
noidectomy and Tonsillectomy, 278—Incision of Pharyngeal 
Abscess, 280—Tracheotomy, 281—Breast Amputation, 282 
—Aspiration; Incision; Resection of Rib (Empyema), 283 
—Appendectomy, 285—Cholecystectomy, etc., 288—Gas¬ 
trostomy, 290—Hysterectomy, 291—Cesarean Section, 293 
—Herniotomy, 294—Nephrectomy (Lumbar Route), 295— 
Curetage, 296—Test for Patency of Fallopian Tubes, 297 
—Trachelorrhaphy, 298—Perineorrhaphy, 299—Hemor- 
roidectomy (Ligation), 299—(Clamp and Cautery), 300— 
Operations to Relieve Fistula in Ano, 301—Fissure, 301— 
Circumcision, 301—Internal Urethrotomy, 302—External 
Urethrotomy, 302—Supra-pubic Prostatectomy, 303— 
Amputation of Leg, 303—Bone Work in Osteomyelitis, 304 
—General Addenda, 304—Emergency Sets, 306. 


CHAPTER XVIII 

Minor Work in the Operating Room . 307 

Intravenous Infusion (Gravity Method), 307—Hypoder- 
moclysis, 310—Injection of Blood-serum, 311—Transfusion, 

312—Administration of Salvarsan (Gravity Method), 313— 
Phlebotomy (Venesection), Open and Closed, 316—Cystos¬ 
copy, 317—Lumbar Puncture, 319—Injection of Serum or 
Anesthetic in Spinal Cord, 320—Artificial Respiration, 321 
—Other Means of Resuscitation, 322—Administration of 
Radium, 322—Forms of Stimulation in the Operating Room 
(Not Previously Given), Coffee Enema, Saline Enema, 323 
—Intravenous Therapy, 323—Treatment for Hemorrhage, 
Primary and Secondary, 323—Hypodermic Injection, 324 
—Abdominal Paracentesis, 325. 





16 


CONTENTS 


CHAPTER XIX 

PAGE 

Relations Between the Superintendent and the Operat¬ 
ing Room. 327 

Surgical Code, St. Elizabeth’s, 333—Buying for the Operat¬ 
ing Room, 335—Trade Names, 337—Whisky and Brandy, 

337—Alcohol, 337—Emergency Orders, 338. 

CHAPTER XX 

Duties of the Nurse in Orthopedic Surgery. 339 

Classification, 339—Definitions, Surgical Diagnosis, and 
Instruments, 339—Apparatus and How It is Used, 341— 
Bradford Frame, 341—Buck’s Extension, 342—Jury Mast, 

344— Fracture-box, 345—Sayre’s Suspension Apparatus, 

345— Modified Buck’s Extension for Hip Disease, 346— 
Orthopedic Tables, 346—Plaster Bandages, 347—Putting on 
a Cast, 349—Lorenz Operation for Congenital Dislocation 
of Hip, 352—Transplantation, 353—New Plaster Knife, 354. 

CHAPTER XXI 

Improvised Operating Room in a Private House. 357 

When Needed, 357—Progress in Serving Communities, 357 
—Preparation of Room, 357—Tables, 358—Anesthetist, 358 
—The Stretcher, 361—Improvised Kelly Pad, 361—Nurse’s 
Supplies, 362—Surgeon’s Garments, 363—Preparation of 
Patient, 364—Demonstration, 364. 


CHAPTER XXII 

The Ideal Surgeon. 365 

Hippocrates, 365—Galen, 366—Guy cle Chauliac, 367— 
Vesalius, 368—Pare, 368—F. Marion Sims, 369—Lord 
Lister, 369. 

Index. 371 








THE OPERATING ROOM 


CHAPTER I 

THE NEW OPERATING-ROOM PUPIL 

“A task!—To be honest, to be kind; ... to renounce when 
that shall be necessary and not be embittered; to keep a few friends, 
and these without capitulation; above all, on the same grim condi¬ 
tion, to keep friends with himself; here is a task for all that man 
has of fortitude and delicacy .”—Robert Louis Stevenson. 

Rotation of Service. —The directress of nurses should 
keep the operating-room supervisor thoroughly posted 
about the pupils’ rotation of service, so that a new pupil’s 
arrival in that department does not interfere with the 
smoothness of its workings. Taking into consideration 
Illness, 

Vacations, 

Other emergencies, 

there should always be one reserve nurse at least in the 
small hospital, more in the large, who is free for call to 
that service when needed. There is a tension and impor¬ 
tance about this “core of the house” that demand a sort 
of militarism in the establishment of a special body of 
nurses “who have had operating room.” To the public 
the operating room holds the seeds of the future success 
of the institution, for surgical results are more tangible 
than medical. Hence, though the personnel shifts, each 
day’s job must be perfect. This demands forethought and 
team-work among the staff nurses. 

The First Day.—The supervisor daily must draw up a 
complete program of how each hour shall be spent by 
2 17 



18 


THE OPERATING ROOM 


each nurse. With a competent senior, she can feel free 
to begin at 7 o’clock teaching the novice her primary 
duties: 

1. The floor plan of the suite, hitherto unvisited. 

2. The personnel, called when needed. 

3. The utensils and supplies to be handled in her first 
shifts. 

The supervisor who would be successful speaks in a 
low, clear, emphatic voice, reaching only the one pupil, 
and not too fast, following home each thought by a study 
of the listener’s eyes to see if she is paying attention, and 
quizzing her for proof of same. The trend of modern 
public school education has not been productive of 
honesty and concentration, therefore the pupil must make 
a tremendous effort to grasp and keep each direction. A 
capable supervisor has a sixth sense that tells her whether 
her instruction is getting through or not. If she feels that 
she is talking to stone, she must persevere till she can 
prove that the pupil can absorb, or is hopeless. 

Psychology of Training.—A new pupil is sent in haste 
by all the corps to find instruments and apparatus. She 
cannot find anything in a moment of panic if she has no 
mental image of it. When a thimble is lost right before 
one’s eyes it is because the mind is on pears or boats. 
One must visualize the thimble. The supervisor is ahead 
of the game by laying out everything that will have any 
possible • bearing on the case, naming each object and 
describing its use, with the aid of the anatomic chart. 
One case is enough to prepare on the first day, so that 
the pupil may stand in the operating room and see the 
process completed. She is guided constantly to form the 
habit of keen observation. 

The Surgeon’s Relation to the Novice.—The successful 

surgeon has an academic relation to the new pupil. 
Apparently unpromising material often makes a substan¬ 
tial, reliable operating-room nurse. The surgeon is a 
teacher, and his obligation to the pupil arises from the 
position he holds on the staff, awarded him by public 


THE NEW OPERATING-ROOM PUPIL 


19 


confidence. Through the shifting of the pupils his work 
flows out into the community, beyond even the bounds of 
the state, by the constant preparation of nurses to carry 
on this department in new or enlarged hospitals. This 
can never be done by ignoring or snubbing a nurse. The 
surgeon is very dependent on assistance from nurses. If 
a pupil appears at a disadvantage, the cause must be 
studied by the supervisor and prevented from happening 
again. Personal interest must be eliminated in the 
operating room. This is the hardest thing to school one’s 
self for in the whole three years’ training, especially be¬ 
cause someone higher up may occasionally be lax. The 
surgeon who is big enough to take no notice of looks, age, 
or anything else not directly bearing on the perfect per¬ 
formance of a task, who can perceive the mental attitude 
of his assistants, and broaden, deepen, or concentrate it by 
Anticipation of his own needs, 

Instruction in running comments, 

Encouragement 

will exert control over the welfare of thousands of people. 

The Pupil’s Responsibility to the Surgeon. —The pupil 
must realize at once that her speed, forethought, and 
presence of mind affect the results of an operation just 
as much as the share taken by any other person. The 
patient on the table may pass out if she fumbles in getting 
a stimulant, and that will he her fault. He may be un¬ 
necessarily weakened by hemorrhage if she forgets where 
the extra hemostats lie. The avenues from the operating 
room to the public life of the community are: 

1. The patient and his family. 

2. The surgeon. 

3. The outside physician who referred the case to him 

and judges his skill by the result. 

4. The patient’s neighbors. 

5. The hospital board. 

6. The undertaker. 

The supervisor should arrange to have strong support 
for the surgeon from the reserve corps when there is a 


20 


THE OPERATING ROOM 


shift in the personnel, but to have the new pupil perfectly 
equipped by chart, instruction, and rehearsal for one case. 

The Operating Room as Related to the Community.— 
Probably no other nurses see so little community life, on 
account of 

1. Long hours. 

2. Emergency calls. 

3. Concentration on one point of service. 

4. Absence of relatives in the field. 

Hence the supervisor must constantly remind the pupil 
of the broadest aspects of her work. The training of 
operating-room nurses is only incidental to the general 
scheme of the community to 
Cure the sick, 

Reduce disease, 

Reduce expense, 

Produce happiness. 

Progress in Methods. —Formerly a new pupil was re¬ 
garded as a maker of supplies, and was set down in front 
of a pile of gauze and told to manufacture it into useful 
forms, supposedly absorbing operating - room methods 
casually in a left-handed way. Then, badly prepared, 
without charts or demonstrations, she was passed on as 
a prop to a critical surgeon. This was the cause of much 
bitterness. Now supplies are made in a supply room far 
from the tense atmosphere of the operating room, but 
under the instruction of the supervisor. They may be 
made b} r 

1. Pupils. 

2. Junior Auxiliary of the hospital. 

3. Red Cross. 

4. Friendly special nurses. 

5. Clean orderlies. 

The pupils are familiar with all forms of dressings 
when they spend a period in the supply room, which is a 
good sedative for the tired or nervous. 

The Telephone. —On account of the longish period oc¬ 
cupied by operations, and the general practice carried on 


THE NEW OPERATING-ROOM PUPIL 


21 


by many surgeons outside, there are frequently pressing 
messages over the telephone not to be found usually in 
ward rounds. The pupil answering the telephone forms 
again a very important link with the community, and 
should take the message with all its details, and deliver 
it thus to the surgeon: 

Dr. -, may I give you a message that is 

urgent? 

Person calling, 

Address, 

Message, 

Time, etc., 

in a clear, distinct tone, close to his side. Then the 
surgeon gives his reply, which she delivers similarly, 
bringing back further conditions if necessary. Were it 
not for this service, a good surgeon might miss being 
called in consultation or other forms of cases. The super¬ 
visor should keep a printed list of the operators and 
those who view or refer cases, especially emphasizing 
foreign names. A local directory with maps is an essential 
feature also, so that odd names of streets, and such 
details as 

Lane, 

Place, 

Terrace, 

Park, 

Avenue, 

Street, 

Highway, etc., 

can be comprehended by any nurse, who may have come 
from Texas or Newfoundland herself. This helps develop 
business acumen too. An operating-room telephone 
should be a desk set, with comfortable chair, pad and 
pencils always sharpened for messages, not a wall set 
with no place to write. 

Morals of Pupil. —The foundation of all operating-room 
work is honesty. The supreme mental anxiety of the 
heads of institutions entrusted with the care of lives and 



22 


THE OPERATING ROOM 


accurate research, who feel that they are leaning on 
some nurses whose daily conversation is a tissue of white 
lies and froth, cannot much longer be uncomplainingly 
borne. Many good nurses are remaining out of insti¬ 
tutional life for the reason that they do not feel they can 
depend absolutely on all the pupils. Hence the operating- 
room supervisor may take each nurse only on probation. 
If she sees tricky deceits, such as 
Omitting dusting, 

Opening the autoclave too soon, 

Measuring medication carelessly, 

Not counting sponges, 

she should be able to get rid of her—back to the wards, 
where less damage can be done, till she makes good again. 
This is no use except with the team-work from keen 
ward supervisors. They should be allowed power to 
punish for petty dishonesty (which can grow). Frank 
talk, constant overseeing, combined with a nice judgment 
of human nature and quick approval for effort to improve, 
may help to correct these obnoxious conditions. Other¬ 
wise the}’’ become a festering sore in the hearts of honest 
nurses. There is a very common feeling that “anything 
is all right if one can get away with it,” but the truly 
professional career of such as believe that is very short 
and disgraceful. If ever at any time in the history of the 
world, as a reaction after the inaccuracies and discrepancies 
in the disjointed period of the war, the honest, dependable 
nurse is widely sought and coming into her own. 


CHAPTER II 


THE CIRCULATING NURSE 

“Life is a patchwork quilt, stitched on the background of Etern¬ 
ity, and padded out with the rags of Time. Strange colors we in¬ 
troduce ! Here a dash of scarlet Passion, there a scrap of pure white 
Faith, then brown Doubt and pale-green Ennui! Most of us, 
however, have to fall back on the dull drab of Work to fill out the 
spaces, and thank God for it, for it rests the tired eyes.”—Quoted 
from an old, old issue of Toronto “Varsity”; student author unknown. 

The Numerous Duties. —This nurse’s work seems hard¬ 
est because it is new and apparently disconnected, a 
heterogeneous mass of “chores,” a bewildering waiting 
on four people at once, all of whom equally insist on 
immediate notice, waiting for seniors to pass, finishing 
up what everybody begins, and jumping at every beck 
and call. Yet the circulating nurse is the foundation of 
success in the operating-room structure. 

Dusting. —The modern principle of using unskilled 
labor where possible does not apply to dusting the operat¬ 
ing room, or to many other duties some nurses would 
like to evade. Dusting in a hospital is a scientific process 
that must be performed by one on whom the institution 
can place responsibility for failure. A diploma cannot 
be withheld from orderlies and maids. Nurses are held 
accountable for all the accessories to the surgical pro¬ 
cedure, including 
Ventilation, 

Lighting, 

Heating, 

Dustlessness. 

Orderlies and maids cannot visualize bacteria, hence the 
work would be done unintelligently, and they are apt to 
leave on a minute’s notice. 

Nurses are members of a class in society, it is sup¬ 
posed, who take pride in work, who work because they 

23 


24 


THE OPERATING ROOM 


know labor is necessary to keep well and sane, who do 
their duty to their neighbor in the community, and who 
wish to satisfy a growing desire within themselves to 
attain more knowledge, more deftness, and general ap¬ 
proval. An onlooker of shallow judgment should not 
give opinions of nurses’ ability. 

Compare Nurse A, 

Who covers a great deal of ground, in long strides 
and strokes, occasionally letting things fall nois¬ 
ily, or breaking a big glass tank worth $50 or 
so, with 

Nurse B, 

Who is less in evidence, but whose work behind 
the scenes is honest and enduring, 

Who boils the water sterilizers long enough per 
schedule, 

Who scrubs every square inch of a given surface 
with Labarraque’s solution and Sapolio, 

Who places every pin in dressing covers with 
meticulous care. 

It is peculiar and unfortunate that the opinion of doctors 
and supervisors seldom coincides about who is a good 
nurse. There is a sort of superficial smartness and pre¬ 
cocity which take very well with surgeons during their 
tense strain. This type of nurse does not work hard and 
painstakingly behind the scenes, cleaning, scrubbing, 
working overtime, or covering required ground. Being 
physically rested and fresh, she appears to give help and 
support, which the surgeon gratefully receives. She 
places herself in an impressionable mood to receive a 
telepathic communication of the surgeon’s next wish. 
She gets credit when little is due. The honest nurse may 
be tired from her conscientious work behind the scenes 
where the surgeon never looks, but she hands him sutures 
aseptically, the water with which he laves his fingers is 
sterile, and the instruments placed in the wound are 
sterile and edged. 

The passing of instruments to a surgeon is the sole 


THE CIRCULATING NURSE 


25 


feature by which he judges a nurse’s ability. But it is 
really such an infinitesimal part of the total operating- 
room work of nurses, or of the surgeon’s entire relation 
to his practice, that it must not overbalance the honesty 
of preparation and after cleaning up. Besides, were it 
only for the criticism of nurses who will always pass in¬ 
struments, it alone is such a little part of the nurse’s life 
and work as a future supervisor, 

(a) In being able to teach it to others, 

( b ) In general morality and thrift, 

(c) In being an example, 

(d) In fitting into the hospital management, 
that it must not be overemphasized. The head nurse 
need not betray the fact that the showy pupil is unthor- 
ough, but must make her do her part perfectly behind 
the scenes also. 

In teaching the pupil to dust a standard method is 
employed, usually coinciding with that of the wards, only 
more complete: 

1. Soap in a basin. 

2. Water in a basin. 

3. Wet and dry dusters. 

4. Labarraque’s solution, dilute for stains. 

5. Bon Ami smeared on glass to dry. 

6. Oxalic acid for rust spots—kept in poison closet. 

7. Sapolio for spots. 

The supervisor should dust the whole suite, then have 
the pupil show by doing each feature that she has ab¬ 
sorbed it: 

(а) Beginning in the corners of window and door 

moldings, thence to center. 

(б) Working around a room in sequence, so as to 

indicate how much is done completely. 

(c) Looking for dirt. 

( d ) Doing highest surfaces first. 

The circulating nurse is not a Cinderella. If she dusts 
the whole suite the day is gone and she learns nothing 


26 


THE OPERATING ROOM 


else. The anesthetic nurse should do her section daily, 
also the suture nurse. 

Dusters of various kinds are needed in large quantities, 
of stout soft cheese-cloth, and dry lintless cloths to dry 
and polish. All articles for damp work are kept in the 
hopper room, which should be well ventilated and sunny. 
Mops, brooms, and brushes for each worker are kept 
separate on tagged hooks, so as to be easily checked up 
or found. Orderlies should do no cleaning higher than 
the floor except the chandeliers—and at all times super¬ 
vised. 

Learning.—In a hospital a pupil learns in two ways. 
Take anatomy, for instance. In class work she has the 
lecture, the chart, and the text-book. In the ward she 
has the doctor, the patient’s wound, and the nurses’ 
conversation. Similarly, in the operating room she is 
assigned certain duties while on a fixed service, e. g., 
circulating, but she cannot help absorbing knowledge 
about the other two services, to which hers is subsidiary. 
It seeps into her system all the time, therefore she cannot 
go to the second or third position totally unfamiliar. 
This equips her for an emergency outside her own field. 
It is not becoming to stipulate how many pupils a hos¬ 
pital will have on the operating-room service, nor how 
long they shall stay, but there is obtainable in the annual 
hospital conferences a fair idea of the proper quota. 

A Place for Everything and Everything in Its Place.— 
The circulating nurse strains every nerve to become a 
good suture nurse. There is a special glory in being able 
to hand a surgeon what he needs before he knows he wants 
it, but it is the flower of a long, painful growth. Daily 
dusting, putting supplies away, preparing for inspection, 
and taking inventory lead up to this. Best of all is the 
morning class in anatomy held by the head nurse. If 
there is a big program the school instructress or an intern 
or a ward supervisor should do it. Third, the working of 
every screw, lever, and button on instruments, cautery, 
and lights must be thoroughly known beforehand, learned 


THE CIRCULATING NURSE 


27 


in a quiet lesson hour, and practised for speed before the 
audience comes. To advance the welfare of pupils and 
patients gives a lofty tone to the supervisor’s work. 

Control of Special Conditions. —In making rounds, the 
supervisor should point out existing difficulties and how 
to obviate them: 

(1) To watch for the backward swing of a certain door, 

with a trayful of instruments, 

(2) To keep screens in all windows, 

(3) To swat a daring fly, 

(4) To reduce noise, 

(5) To keep steam out of the main room, 

and show what the ideal conditions are, to foster in the 
pupil’s mind the ideas which may result in finer construc¬ 
tion or equipment in future hospitals. This quickens the 
dry bones of the daily round. 

Utensils. —The care of utensils comes next. Enamel- 
ware, glass, metal, baskets, brushes come under this 
heading, each with its formulae. (See chapter on For¬ 
mulae.) Here the relation of this duty to the surgeon 
must be shown. He runs a big risk when beginning to 
scrub up if he handles a brush not thoroughly cleaned after 
a pus case. The whole suite is a cobweb of points of con¬ 
tact between surgeon, patient, and nurse. 

Linen. —The circulating nurse sorts linen to go down the 
chute to the laundry, all clots being washed out first in 
cold water and wet linen tied in separate bundles. Iodo¬ 
form linen goes also in separate bundles. By a carefully 
trained laundry head co-operating with the superintendent 
of nurses a strict check can be kept, by the hour when 
sent, as to who let go down the chute 

(1) An instrument of delicate make and value, 

(2) A small pillow, 

(3) A rubber sheet. 

It is the lesson of a lifetime to make haste slowly with 
linen, instruments, and other equipment which is of 
untold value when it is needed. It is embarrassing to 
face the august business superintendent for destruction 


28 


THE OPERATING ROOM 


of hospital property, returned from the laundry via his 
desk. One reprimand should be enough. If the offence 
is repeated the pupil’s privileges should be temporarily 
withdrawn. The laundry man clears away the operating- 
room chute more often than the others for the sake of 
quick turnover of goods. 

Counting Linen.—A modern building is so planned that 
nobody can steal linen. It is a circulatory system with¬ 
out any vents. The employees file out of one door past 
the offices, carrying no bundles without exciting the 
suspicion of the watchman. Operating-room linen is 
marked plainly, and of a different 
Texture, 

Color, 

Pattern, 

Laundering 

from that of the wards. Ward supervisors finding it 
among their stock should report to the head of the laun¬ 
dry, and return it to where it belongs. The circulating 
nurse should see her linen taken from the chute, washed, 
mangled, and sent up, so that she can determine how to 
locate missing or destroyed articles. When a patient is 
sent to the ward the accompanying nurse should bring 
back all operating-room linen to go down its own chute 
and come back more quickly. The ward pupil receiving 
the patient should inspect the bed thoroughly at once, 
to get rid of all pus basins, clamps, chest blankets, or 
towels. However, it is not necessary to count the articles 
on account of the sealed route in which they travel, 
merely to scan their condition, as to need of repair, on 
return. 

Building the Stretchers.—The pupil here learns the 
borderline between operating-room and ward supplies. 
When it is “for the good of the service” that she reclaims 
her own towels or sheets from the ward nurse’s reach, 
and not as personal property, there need be no tartness 
of temper displayed at these contacts. The nurse should 
visualize herself as the patient on the stretcher, needing 


THE CIRCULATING NURSE 


29 


Heat: Blankets of special color—red reveals no blood¬ 
stains. 

Lifting: Stout short sheets of unbleached muslin—two 
persons. 

Person at the head—anesthetist. 

Person at the foot—ward nurse. 

Covers: Chest blanket to prevent pneumonia. 

Cap over head in good shape, to mask identity 
en route. 

Protection from vomitus: Towels and basin at chin. 

Surgical dressing: Binder, warm and dry, laid in posi¬ 
tion, if not applied on table. 

Dress.—The circulating nurse should be easily picked 
out, wearing an operating-room cap, but no mask, and a 
gown with special pockets for pencil and pad, suitable 
shoes for tiled floor, and rubber heels. 

Applying Binders.—The Scultetus binder should be well 
ironed and dry. For a laparotomy the pressure is first 
exerted at the bottom, braiding toward the top; for an 
obstetrical case the pressure is first exerted at the top, 
braiding toward the bottom. This must be done very 
well and quickly, 

(1) Before vomiting might begin, 

(2) To keep the abdomen from chilling. 

A long, solid footstool is necessary to give a short nurse 
purchase, to tighten the binder at this unusual height. 

Scrubbing Up.* —Far be it from a nurse to dictate the 
best method of scrubbing up, as opinions on this vary 
widely in the well-regulated operating rooms. The main 
principles are: 

1. Genuine personal cleanliness in general, nails trimmed 
very close. 

2. Removal of dirt by soap and brush, systematically 
following the pattern of the hands. 

3. Loosening under the nails. 

4. Scrubbing again. 

5. Disinfecting in soak of prescribed solutions. 

6. Drying with sterile towels. 


30 


THE OPERATING ROOM 


7. Donning sterile gloves. 

8. Tests by the pathologist at unexpected times. 

“A chain is no stronger than its weakest link” is the 
universal motto of surgery. The circulating nurse is 
quietly watched by all the oldsters when she first scrubs 
in the amphitheater, and if she silently minds her business 
and works honestly for the stipulated period she gains 
the first lap in their confidence. She can make or mar the 
operation. Donning a mask before and a gown after the 
scrub complete the preparation when going to take part. 

Holding Retractors.—She is frequently called to hold 
retractors, being physically more fresh than the seniors who 
are depleted by a long term in superheated air. Hence her 
knowledge of asepsis and her conscience are tested early. 

Setting Up.—She may be taught to set up for any cases 
short of laparotomies and bone-plating. There are nice 
shades of difference as to 

(1) The extent of the field, 

(2) The rigidity of asepsis, 

(3) The strength of disinfectants, 

(4) The preparation of instruments 

between a strabismus operation and a herniotomy. The 
circulating nurse may set up, and work to the point where 
the suture nurse may carry on when the surgeon arrives, 
in running off a big program in two or more rooms. 

Regular Duty of Circulating Nurse During Operations: 

1. Furniture is wiped off with 5 per cent, carbolic acid. 

2. As listed for her, she lays out 

Gowns, caps, brushes, 

Table covers, towels, 

Sponges, bandages. 

3. Carries in solution basins, fills them. 

4. Opens jars without contaminating and recovers. 

5. Carries in instrument tray, holding it well out from 

her body. 

6. Picks up, washes, and boils all dropped instruments 

the proper length of time, carrying watch, to 
prove herself right. 


THE CIRCULATING NURSE 


31 


7. Lifts special basins out of utensil sterilizer with 

forceps (Fig. 1), so that her head and arras do 
not hang over the tank. 

8. Fills basins with sterile water from pitcher covered 

with a folded towel, through which loop she slips 
a finger to uncover it. 



Fig. 1 . —Sterilizer forceps for removing basins from the utensil 
sterilizer. 

9. Tests certain solutions with glass thermometer 
floating in a harmless disinfectant and lifted by 
forceps. 

10. Never takes anything off sterile tables. 

11. Administers or prepares for 

Hypodermic, 

Lavage, 


32 


THE OPERATING ROOM 


Enema of coffee, 

Lumbar puncture, 

Intravenous infusion, 

Catheterization, 

Douche, 

Hypodermoclysis, 

and records same on chart over her own 
signature. 

12. Renews supplies for anesthetist. 

13. Takes nursing charge of patient when necessary. 

14. In bone-plating, resterilizes every instrument when 

used once, and keeps the small sterilizer boiling. 

15. Runs the cautery. 

16. Keeps the sponge count—picks up with forceps and 

counts soiled sponges. 

17. Covers the patient with hot blankets from the 

warmer when in shock. 

18. Drapes the patient in first drape, with unsterile 

sheets, with warm towels on the Kelly pad. 

19. Puts the patient in 

Trendelenburg, 

Sims, 

with feet well wrapped in thick blankets when in mid air. 

20. Never is missing when needed. 

21. Presents privileged visitors with armless gowns. 

22. Keeps all plumbing fixtures clean. 

23. Throws bloody towels at once in hopper in cold 

water. 

24. Prepares all specimens for the laboratory, marked 

with names of surgeon and patient, ward, date, 
and tentative diagnosis, particularly from right 
and left ureters in cystoscopic work , a matter of 
life or death to the patient. 

25. Does not remove the specimen basin till the surgeon 

orders, so that he may study his work. 

26. Places various sizes of sand-bags under neck or by 

limb as ordered. 

27. Turns tonsil cases on side to bleed in pail as re- 


THE CIRCULATING NURSE 


33 


quired, and slaps on ice towels to relieve hemor¬ 
rhage and restore consciousness with good cir¬ 
culation. 

28. Telephones to the ward to arrange for 

Gatch bed, 

Stimulation, 

Murphy drip. 

29. Writes orders in the ward order book at the dicta¬ 

tion of the intern. 

30. Keeps all sorts of work hustling behind the scenes, 

Washing gloves, 

Running sterilizers, 

Linen soaking, 

Sorting covers. 

31. Drops 

Acetanilid, 

Aristol, or 
Collodion 

on a wound in an aseptic manner, wiping off the container 
with damp bichlorid cloth, and winding sterile towel 
around her right arm (Fig. 2). 

32. Shaves emergency cases or those improperly pre¬ 

pared. 

33. Finds additional instruments required. 

34. Applies bandages. 

35. Produces smear-glasses, slides, culture-tubes, and 

swabs as needed. 

36. Washes and boils those special instruments which a 

surgeon wishes to take away with him (if the 
suture nurse has not time) while he is in the 
shower-bath. 

37. Waits upon the surgeon, if he gets a squirt of blood 

or pus in his eye, with boric acid and argvrol, 
and if he jabs his finger in a dirty case, with car¬ 
bolic acid and alcohol, or with iodin. 

38. Records the amount of catgut or the number of 

gloves used, if, as some institutions do, it is 
charged to the patient. 

3 


34 


THE OPERATING ROOM 


39. Keeps empty covers collected and sorted in their 

. various baskets, ready to be refilled. 

40. Bed-pan is required sometimes, and must be in 

readiness, with cover and sponges for cleaning 
parts. 



Fig. 2.—Dusting aristol on a wound. 


41. After pus case, disinfect linen before putting down 
chute, for protection of all patients and em¬ 
ployees. Wash furniture with soapy water, then 


THE CIRCULATING NURSE 


35 


disinfectant. Wash and boil separately all in¬ 
struments, gloves, and basins. 

42. Kelly pads are soaked in disinfectant after every 
case. Two at least are kept working. Some 
surgeons think they are never “clean,” i. e., 
• germ free. 

The Engineer as Instructor. —He personally instructs 
and supervises the work of the nurses in frequent visits 
regarding 

Lights, switches, fuses, 

Valves, stopcocks, petcocks, faucets, 

Cold coils, water-jackets, steam-jackets, filters, 
gages, 

Foot-treads, sprays, soap-holders, 

Traps, waste-pipes, flushes, 

In gas, water, and electricity 

based on notes drawn up by the supervisor. This will 
result in perfect working of all appliances if the nurse is 
led to feel that he has authority, and this he certainly 
should have owing to: 

The possibility of accidents of serious nature, 
Difficulty and delay in repairs, 

Peril to other parts of the house, 

Enormous costs in engineering department due to 
Its being a profession in itself, 

High scale of wages, 

Delicacy of parts of machines. 

Changing Cases. —Rehearsal is necessary with the new 
pupil in order to establish a system that has speed and 
smoothness. The suture nurse near the close of the first 
case begins to get ready for the second, sending out what 
she has finished with in two classes: 

(a) To be used in the next case, washed, and boiled. 

(b) Not needed again—put to soak. 

1. Instruments of different men or for various operations 
are 

Grouped in separate basins, tagged if necessary. 
The new pupil should keep her mind entirely on 


36 


THE OPERATING ROOM 


her work, to form grooves of association of ob¬ 
jects with their owners, and the purpose for 
which they are used. 



Fig. 3.—Offering a glove case. 


2. The orderly mops the floor. 

3. The circulating nurse washes the table with soap, 

then carbolic acid, if it is to be left in position, 
then spreads it with sheets, etc. 






THE CIRCULATING NURSE 


37 


4. She removes used solutions and basins. 

5. She waits on the clean suture nurse, 

Opening packages, 

Removing pins, 

Adding to the stock, 

Replenishing the sorub-up stand, 

Getting basins p. r. n. 

6. She waits on the surgeon and his assistants. 

There is nothing so thrilling or so completely soul- 
satisfying in all the work of the operating room as the 
quick, clean, smooth turnover of a number of cases in a 
big clinic with one surgeon. 

Special Notes . . . Addenda: 

1. If dressing covers are frequently laundered, they 
last longer, and are more suitable for holding sponges. 

2. When tying a doctor’s gown she thinks with her 
outer clothing. The nurse touches only the tapes. 

3. All packages are carried well out from the body, 
never under the armpit ; similarly when offering (Fig. 3). 

4. There should be a carefully compiled book of house 
rules in every hospital, consulted often by everybody. 

5. The circulating nurse should never be absent when 
needed; she must project her attention into the amphi¬ 
theater, mentally following procedures there, when she is 
outside timing the boiling of a forceps. 

6. She should be able to perceive with her skin, her 
clothing, her back hair, or to have a sixth sense to know 
how to avoid touching a sterile surface, or report when 
wanted. 

7. Water that is too hot makes a surgeon indignant. 
Water that is too cold shocks a patient. To avoid this, 
read rules and use thermometers. 

8. A surgeon sometimes uses a sponge as a plug or for 
backing in a vagina, and if asked to remember this, the 
circulating nurse must charge her mind with it. It is an 
honor. 

9. The circulating nurse must keep looking for some¬ 
thing to do. 


38 


THE OPERATING ROOM 


10. Plenty of brushes dry sterilized obviate the diffi¬ 
culty formerly found in boiling so many kinds of things 
between cases. 

11. It is very essential to have a large number of binders 
of assorted sizes and well ironed. 

12. The solution in arm-tanks is changed for a new 
operator, but not for one man unless the last is a pus case. 

13. Safety-pins should be stood in rows on their points 
around the edge of Castile or Ivory soap as a lubricant 
for quick work. 

14. Dermoid cyst, fetus, or other solid specimen is 
saved as a routine and preserved in 4 per cent, forma¬ 
lin. Priceless specimens have been carelessly thrown 
away. An eye should not be put in alcohol, which 
shrivels it. 

15. The pail below a tonsil case helps show the amount 
of bleeding. 

16. Doors should be kept closed. 

17. By being all eyes and ears the circulating nurse can 
make a shrewd forecast of what is next needed. 

18. It is pleasing to win the respect of surgeons by 
applying good bandages—most of them have lost hope in 
the nurses for that. 

19. In certain laparotomies the surgeon slits the culde- 
sac of Douglas, and passes down an iodoform gauze strip, 
which the circulating nurse, wearing a glove, catches in 
the bite of a sterile uterine dressing forceps. This glove 
must be ready. The nurse requires a lesson by charts and 
drawings on the anatomic relation of the bladder, vagina, 
and rectum. 

20. A small bunch of twigs or a flat wire egg-beater is 
good in whipping out the fibrin of blood-clots when 
searching for specimens. 

21. Garbage cans and similar utensils should be oper¬ 
ated by a foot-tread, not by the hand. 

22. The nurse must wield the mop in an emergency. 

23. The nurse must be very meticulous about personal 
hygiene, bathing twice a day if necessary, wearing dress- 


THE CIRCULATING NURSE 


39 


shields frequently washed, and no perfume or scented 
powder. The hair is washed often. 

24. The stretchers must be kept warm, clean and dry 
from a table stocked with adhesive, binders, dry shirts, 
and sheets. 

25. If a patient swallows ether by the esophagus route, 
and thus dilates his stomach, the anesthetist calls for the 
lavage tube, inserts it, and elevates the open end, through 
which the ether escapes, and the patient may then be 
regularly anesthetized. 

26. The circulating nurse early is taught the contents of 
instrument cabinets, which are arranged per schedule: 

(a) Owned by certain surgeons, 

(b) Classified types of surgery—eye, ear, gyne¬ 

cology, etc., 

(c) Steps in each operation—incision, clamp, liga¬ 

tion, etc., 

so that she may easily find a special article when needed 
during an operation. 

27. The circulating nurse should sit when tired, for 
conservation of strength, till she is gradually inured to the 
hardness of the flooring, which lacks the resilience of those 
on the wards. 

28. When the anesthetist is covered with a sheet he 
must be specially assisted in small ways, e. g., in a hare-lip 
operation, so that he is not smothered in his own C0 2 . 

29. Summary of treatments for shock or hemorrhage or 
danger of death from other causes: 

(a) Elevate feet, 

(b) Hypo, ordered, 

(c) Heat (water-bag and blankets), 

(d) Hot towels to exposed intestine p. r. n. 

(e) Air, 

(f) Oxygen, 

(i g ) Intravenous infusion, 

(h) Hvpodermoclysis, 

(i) Cessation of operating—clamps and ligatures 

only, 


40 


THE OPERATING ROOM 


(j) Possibly more ether, 

(k) Artificial respiration, 

(l) Scientific massage of heart muscle, 

(m) Rectal speculum, dilatation of sphincter, 
(ri) Transfusion. 



Fig. 4.—Wiping perspiration from a scrubbed nurse’s brow. 


30. When wiping perspiration off the brow of anyone 
who is scrubbed, the circulating nurse “makes a long arm” 
to it, wound in a sterile towel (Fig. 4). This has be¬ 
come less necessary since masks are in vogue. 


THE CIRCULATING NURSE 


41 


Sponge Count. —Reasons pro and con: 


Pros. 

A check on the surgeon, who in 
haste and preoccupation might 
leave one in the deeper cavities. 

Ensures more care and obser¬ 
vation in the surgeon and his as¬ 
sistants, so that they cultivate 
the habit of not leaving small 
sponges free. 

Ensures concentration on her 
job by the pupil. 

When the sponge count is re¬ 
ported not 0. K. the surgeon may 
be right, and the missing sponge 
may be found under some one’s 
shoe, etc., proving the value of 
the system. 

A trap may be set for each new 
circulating nurse, by the sur¬ 
geon’s wilfully withholding one 
or more sponges when he asks for 
the count, thus testing the hon¬ 
esty of the nurse. 

Honor at close grips with a pa¬ 
tient in dangerous condition is 
highly essential. 

A slip with the name of the 
nurse who packs the drums might 
concentrate her attention on 
doing it carefully. 


Cons. 

Delay to a patient when a dis¬ 
crepancy is found is unpleasant, 
an added duty for the busy cir¬ 
culating nurse. 

She is blamed, when the mis¬ 
take may be with the person who 
filled the dressing covers. Care¬ 
lessness in another place not re¬ 
cently is hard to trace. 

Possibly the pupil is so busy on 
such details that she cannot see 
the woods for the trees, and misses 
the more important lessons from 
the progress of the case. 

It looks like dirty work to pick 
bloody sponges out of a pail, no 
matter how long the forceps are. 

The percentage of times that 
the sponge count is reported 
O. K. is so very large that it 
seems to some not worth while to 
have it. 

It requires the attention of the 
suture nurse to count the sponges 
as she opens the covers or drums. 

The penalizing of nurses for 
error is reduced to a minimum in 
these days for everything, and 
this type of error is no more se¬ 
rious than a falsehood about a 
Murphy drip. 

Honor is essential toward one’s 
patient at all times, no more for 
one than another. 


It is interesting to note the manner in which an institu¬ 
tion changes its policy. For ten years an operating room 
runs smoothly without a sponge count, then a sponge is 
left in a patient, who dies. After this for ten years more 
the sponges are all counted, till all fears are lulled to 
rest and the count discontinued. It must in any case be 
the policy of the majority, and evolved after due reasoning 
together, under the segis of the American College of 



42 


THE OPERATING ROOM 


Surgeons. A blackboard is often used, also a rack on 
which to hang tapes by rings. 

Washing Sponges.—Bloody probangs require long soak¬ 
ing in cold water in a hopper, after being huddled out of 
the operating room in pails, following the count. To 
soak articles thus prevents a hopper from “working,” 
i. e., free use by all for varied purposes. To launder these 
sponges properly demands their being handled seven times 
more, or eight times in all, at least. Suppose eighty 
sponges were used. These are made at the rate of sixteen 
to the yard. This means five yards of gauze which the 
hospital can buy at less than 4 cents—20 cents at the 
most. It is false economy to ask a pupil or a graduate 
who is worth at least 50 cents an hour or a laundryman 
with a costly machine, at much more cost than this, to 
spend two or more hours in these frequent handlings of 
material that costs only 20 cents. Further, the laundered 
gauze requires much pulling and raveling to use again in 
surgery. It might be sold for rags. Nothing should be 
washed, but it is a very unwise thing to avert the destruc¬ 
tion of sponges, which may carry syphilis, gonorrhea, 
other blood infections, or pus lying latent in the person 
up for operation. The cost of disinfectants and the time 
required by laborers very highly skilled in other fields to 
salvage this messy stuff and bring it back to scratch, where 
the new gauze starts, are too great for a shrewd head to 
approve of. By the common household methods of 
laundering, a steadily working woman could not earn her 
keep ($4.00 wages, 50 cents lunch, and 10 cents carfare = 
$4.60) keeping up with a suite of operating rooms, and 
having all the sponges dried and pulled by 5 p. m. ready 
for making again; $4.60 4 cents =115 yards gauze = 

1840 sponges, representing at least 10 major operations. 
Few operating-rooms use 115 yards per day. Reductio ad 
absurdum (et ad nauseam). 

There is no doubt that tape sponges should be washed 
and used again because the labor of making them render 
it worth while, also the amount of gauze in each. 


CHAPTER III 


THE ANESTHETIC NURSE 

Definition.—The anesthetic nurse is the pupil on second 
shift in the operating room, waiting on the patients while 
they are taking ether or gas, to differentiate from a nurse 
anesthetist who is a graduate being or having been trained 
in giving anesthetics. 

Instruction.—In the anesthetic room the supervisor must 
demonstrate very carefully, using the pupil as subject, for 
several days before she changes from circulating to this 
service. a Put yourself in their shoes” is a safe slogan for 
pupils in relation to patients anywhere, but particularly 
in the operating room, where, unfortunately, entities are 
forgotten. When the pupil demonstrates before the super¬ 
visor, the subject used should be the fattest, clumsiest, 
stupidest person that can be found, in order to stage some 
of the difficulties bound to arise during the stage of excite¬ 
ment, due to 

1. Patient’s weight, 

2. Disease, deformity, or lesion, 

3. Fear of anesthesia, 

4. National temperament and habits. 

The supervisor lays down the following general instructions: 

1. Obtain plenty of assistance: 

Orderly, 

Restraining bands. 

2. Take time to place the patient properly, but learn 
and practice beforehand, not to detain a busy surgeon. 

3. Report to surgeon when anesthetist requires. 

4. Do not allow anyone to throw himself across the 
body of a struggling patient, having his lesion in mind, 
e. g., a fulminating appendix. 

5. Avoid bruises or jars, as the flesh is unduly sensitive 
when anesthetized. Unaccountable bruises caused hos¬ 
pitals ill repute for years. 


43 


44 


THE OPERATING ROOM 


Positions.—In all positions a small sheet, folded to 6 
inches wide, is looped around each elbow and tucked 
under body. 

(1) Dorsal: 

Patient flat on her back, from head to heels. 

Hands are always laid flat under buttocks. 

Knees may be sharply flexed, with heels on level 
with hips. 

Used in general surgery. 

(2) Kidney: 

Modification of same. 

Patient lies on her face, arms above head. 

Cylindric inflated rubber bag under abdomen to 
push up kidney. (A badly placed kidney rest 
delays the operation, lengthens the anesthesia, 
annoys the surgeon, and possibly chokes off 
the patient’s respirations; also if the arms are 
under the body, temporary paralysis may 
ensue.) 

(3) Sims: 

Should be learned previously on ward in giving 
enema. 

Remove pillow and lift patient to her left side. 

Left knee drawn up toward chin, so that left 
thigh is at right angles to side of table. 

Right knee drawn up much farther—this opens 
rectum and vagina—abdomen pendant. 

Hips well over edge of table to soften the parts. 

A real Sims’ table has an extension on the side for 
the feet. 

Left arm is gently withdrawn from before breast, 
and brought in a downward sweep behind her, 
at the right edge of the table. 

Her chest is flat on the table, and her face turned 
to the left side of the bed, her right arm curved 
over head. 

Sand-bags to immobilize. 

Used in gynecology and obstetrics. 


THE ANESTHETIC NURSE 


45 


(4) Lithotomy: 

Patient lies flat on the table, drawn down with 
the Kelly pad underneath, so that hips are 
beyond the break in the table, and when the 
foot is dropped the buttocks hang over the end. 

Apron of Kelly pad breaks at proper place. 

Each foot is hung in a stirrup passing 

(1) Behind the heel (tendo achillis), 

(2) Under the arch. 

(Screws of stirrups must be kept well oiled, to 
work easily, and be frequently tested before 
operations.) 

Stirrups have a special conspicuous place in room, 
to find easily. 

Surgeon must not be irritated by having to ask 
always “to bring the patient down a little 
farther.” 

Arms strapped, and hands flattened under but¬ 
tocks. 

Bars must be well nickeled and rustless, also 
lubricated. 

Used in gynecology, rectal and genito-urinary 
work, also for breech cases in obstetrics. All 
soft parts must be free from pressure and 
relaxed. 

Stirrups should throw legs farther apart, to give 
operator room. 

(5) Knee-chest: 

The patient is not anesthetized. She kneels on 
the table, so that when the foot is let down her 
buttocks are vertically above—face down, 
turned slightly, knees at breast—support given 
beneath her abdomen by nurse. 

Used in cystoscopy, rectal work, and convalescent 
obstetrics (counteracting retroverted uterus). 

(6) Trendelenburg: 

When gynecologic work is required Trendelenburg 
may be most frequently expected, and prepared. 


46 


THE OPERATING ROOM 


The knees must be about 2 inches below the joint 
in the table, so that when the foot drops the bulk 
of the calves finds room in the right angle formed. 

The limbs are securely pinned in a small heated 
woolen blanket about 1 yard square, brought 
around from behind them, caught up at the feet 
into the pocket and pinned in front. 

The shoulders are set against two shoulder props, 
which must be newly and fatty padded to pre¬ 
vent paralysis of the trapezius muscle. Fitting 
them on the table properly requires study. 

The modern table is wound up or lowered by the 
anesthetist, and he should insist on lowering it, 
if the patient “goes bad.” 

Used in gynecology for deep pelvic work. 

(7) Sitting: 

For eye or tonsil under local anesthetic, or for 
neck, use dorsal, with head of table raised half 
right angle. 

(8) Gall-bladder: 

Put pad under back, on right side to force liver 
out under lower border of ribs. 

(9) Pinioning Children: 

Use a very large face towel or small special oblong 
sheet. Lay the child on the towel, at the hips, 
long edge horizontal, and pin up the front. 

Pin the child’s sleeves in front, or at side, folding 
arms, or straightening. Then reverse towel, to 
the head. Make darts of equal size on the 
shoulders to make it snug. 

Suitable for staphylorrhaphy. 

Methods with Tables: 

A. Fixed: 

1. Many operating-room suites have rooms de¬ 

voted each to one purpose, eye room, eye 
table, etc., fixed. 

2. Others have fixed tables with various attach¬ 

ments to suit all different types of surgery. 


THE ANESTHETIC NURSE 


47 


When the table is fixed the patient is anesthetized 
and brought in on a stretcher, necessitating 
lifting. 

B. Movable: 

1. If a surgeon has invented a special table, he 

wants it, and though another good table is a 
fixture, he chooses a smaller room, with his 
patient wheeled in, draped, all ready. It 
reduces the number of liftings. 

2. The table may be run directly to the patient’s 

room for her and to bring her back. 

3. To have several tables facilitates running off a 

big clinic smoothly, from the nursing stand¬ 
point. 

4. The patient is ready on her own table, and does 

not rush the cleaning of equipment pre¬ 
viously used. 

C. Combination: 

Fixed and movable (see Jour. Amer. Med. Assoc., 
September 29, 1923). A very clever device 
has been made in Philadelphia recently, 
combining all the advantages of both fixed 
and movable tables. In the operating room 
is a fixed stand (pedestal or legs) with re¬ 
movable top. The stretcher carriage is built 
to receive or discharge this top. Both table 
and stretcher bear on top tracks with grooves, 
and in direct alignment. An interlocking de¬ 
vice prevents them from going apart when 
brought alongside. The patient is anesthe¬ 
tized on the stretcher, wheeled in beside the 
table base, both are locked together, and by 
a mere touch, the top slides over in the 
grooves of the table base. This is reversed 
when the case is finished. One table, one 
stretcher carriage, and two tops (litters) are 
enough to run off a big clinic smoothly. 

Setting Up the Anesthetic Room.—The anesthetic 
nurse sets up her room for a clinic as follows: 


48 


THE OPERATING ROOM 


Apparatus 

Gas-oxygen set 
(Fig. 5), 

Inhalers, 

Tripods, 

Face masks, 

Cones made from 
towels, 

Vaselin for rectal 
tips, 

Cold cream for face, 
K. Y., 

Soft straps for knees 
as restraint in co- 
cain and gas-oxy¬ 
gen, 

Hot-water bag, 
Lifting: 

Cloth stretchers, 
Sheets. 

Ether, 

Chloroform, 

Cocain, 

Novocain, 

Quinin and urea, 
Pins: 

Straight, 

Safety-, 

In soap, all sizes. 
Jack knife to open 
cans, 

Waste baskets, 

Pus basins, one high 
wall 

Several sponge for¬ 
ceps 

Tongue clamps (Fig. 

6 ), 

Tongue sutures, 
Mouth-gags (Fig. 7), 
Oral screw, etc. 
Bed-pan With 
Urinal / covers, 
for nervous pa¬ 
tients, 

Bandage scissors, 
Lavage set, 

Pocket light, 

Nurse's wrist watch, 
Pulmotor (Fig. 9). 


Stimulation 

Means to heat. 

Hypo syringe and 
sterilizing outfit, 
morphin, atropin, 
strychnin, digitalis 
in modern forms, 
whisky, brandy, 
camphor in oil, 
emergency Greeley 
units (small glass 
tube showing the 
dose specified on a 
legible printed 
slip, with a fixed 
needle, ready pro¬ 
tected with sterile 
cover, and soft 
compressible tube 
[cold cream type] 
which forces, when 
squeezed, the fluid 
through the bared 
needle). 

Large assortment of 
drugs and doses of 
these. 

Files coming with 
ampules must not 
be lost. The con¬ 
tents of an ampule 
are easily drawn 
from a sterile 
spoon into a syr¬ 
inge, if thick. 

Speed and accuracy 
are two potent ad¬ 
vantages with am¬ 
pules and Greeley 
units. 


Dressings 

Eye protectors, 
Sponges, 

Mouth wipes. 
Bandages of all 
widths: 

Muslin, 

Gauze, 

Flannelette. 

Stationery 

Pen, 

Ink, 

Scratch pads, 
Anesthesia slips. 

Garments 

Binders: 

Scultetus, 

Perineal, M and 
F. 

Chest blankets. 

Caps of 
Rubber, 

Towels (Fig. 8). 
Foot blankets, 

Large blankets, 
Sheets, 

Medium and large 
towels, 

Triangles, unsterile. 


THE ANESTHETIC NURSE 


49 


To speed the work there should be a standard number 
of all of these, constantly replenished. At a glance one 
can tell how much has been used. 


Fig. 5.—Gwathmey gas-oxygen apparatus. 

Needs of the Nurse Anesthetist.—She usually uses the 
nurses’ dressing rooms, therefore her caps, gowns, etc., 
are to be laid out there. Her upper garment is a loose 

4 












50 


THE OPERATING ROOM 


short smock, in the form of those worn by peasants, with 
a belt, to which are conveniently clamped the gag, tongue- 


clamp, and sponge forceps. 



Fig. 6.—Tongue clamp with soft- 
rubber tips. 


Wrist watch and cap, white 
skirt and small mask for 
special cases, complete the 
costume. These garments 
are not sterilized. A good 
anesthetist does not call 
the nurse from her numer¬ 
ous duties if possible. 



Fig. 7.—Mouth-gag. Oral screw, 
hard rubber or boxwood. 


The Rights of the Patient: 

A. Safety: 

(1) False teeth, 

Loose teeth, 

Crowns, 

Bridges, 

Might cause choking, 

Must be removed and labeled and laid 
away in a safe place, if forgotten on the 
ward, being very costly and difficult to 
get. 




THE ANESTHETIC NURSE 


51 


(2) Hairpins, 

False hair, 

Jewelry, 

Artificial limbs 

Must be removed and kept, as they might 
wound the patient, be lost, or obstruct 
the operation. 



Fig. 8.—A serviceable “ether” cap for all purposes. 

(3) Wedding ring may be tied with half-inch tape, 
one knot in the ring, one at the back of 
the wrist, and one below the palm. 



52 


THE OPERATING ROOM 


(4) Voiding urine must be carefully watched for, 

due to nervousness or the sequelae of old 
scarlet fever, or to the long wait. A full 
bladder is dangerous because: 

(a) It is unexpected and rips if barely 
touched with scalpel or scissors. 

(i b ) Free urine in the abdomen is a poison¬ 
ous foreign body, retarding or pre¬ 
venting recovery. 

(c) The bladder wound itself heals very 
slowly. 

If the patient has not voided before the 
anesthetic, this is reported to the surgeon 
verbally by the anesthetic nurse even if it 
is charted. 

(5) Chilling may happen, due to opened pores, 

hence chest blankets. The gown is loosened 
at the neck to permit distention of the 
blood-vessels during the period of excite¬ 
ment. Do not cover the eyes till after the 
noise of filling the gas-bag subsides. No 
delay is permissible after this. 

(6) The patient must not be left alone one second. 

B. Consideration .—The whole family of a patient is 

under strain while the anesthesia lasts. They should be 
patiently and kindly treated, especially as doctors and 
nurses themselves make most difficult patients. The 
nurse and others should be calm, quiet, and kind, with a 
cheerfulness belying any doubt of the result. The anes¬ 
thetic nurse may be the last person the patient will ever 
see. To all persons the loss of consciousness is the big 
thing, not the operation itself, hence the effort of profes¬ 
sional persons to be operated on with local anesthesia. 
The fact that patients are anesthetized as routine in large 
numbers should help a nurse to develop that side of her 
nature, and not make her callous, noisy, and indifferent to 
details. The orderly who brings up the stretcher must 
disappear and go on with other work. He may be called 


THE ANESTHETIC NURSE 


53 


during the stage of excitement and again in taking in the 
patient, but the woman should not have cause to fear that 
he would be present when she was draped. Spiritual con¬ 
solation should always be accorded a patient before the 
anesthetic if required, especially for the benefit to the staff 
through the patient/s peace of mind. The patient must 
not be exposed at any time, except the operative field. 
The cap on the head is well pulled down to mask identity 
in transit, because all one’s looks vanish. In whisking 
off soiled sheets, a blanket is first laid above all. The 
handling is done as if the patient were conscious. For 
their own sakes, nurses must handle patients modestly, as 
well as for the onlookers. 

Lifting Patient Skilfully. —The nervous patient prefers 
to climb from her bed to the table, in her own room, 
because the finality of the gesture is comforting. In 
transferring from stretcher to table, or from stretcher to 
bed, the rules are: 

1. Anesthetist lifts head and shoulders, watching pus 
basin also. 

2. Anesthetic nurse and orderly lift hips by means of 
small stretcher sheet. 

3. Circulating nurse lifts feet, and frees arms from arm 
guards. 

4. In ward, ward nurse should kneel on bed to receive 
patient, if necessary. This reduces her own body strain 
from the width of the bed. 

5. The anesthetist is in charge, and, to secure unison, 
he counts “one, two, three!” and, on “three,” all lift 
together. 

Great care must be used after bone-plating or trans¬ 
plantation. 

The supervisor should have a recognized authority to 
break in the new anesthetists to do their share of lifting. 
In transit, the patient’s arms must be watched, especially 
at doorways, and the best way to protect them is: 

1. To pin cuffs together over chest, or 

2. To flatten the hands under the buttocks, and 


54 


THE OPERATING ROOM 


3. To bind securely with a large blanket , brought up 4 
from beneath the patient. 

4. Arm guards are used on the operating-tables. 

Problem. —Should nurses administer anesthetics? 

1. Graduate Nurses .—The small and ever-shrinking 
ratio of medical students to the population is alarming at 
present. The moral, educational, and financial require¬ 
ments are high. The austerity of the life of devotion is 
tremendous. Fewer men are found who have the first 
and accept the second. This is one cause for the em¬ 
ployment of graduate nurses as anesthetists. However, it 
is only robbing Peter to pay Paul, because there is a 
shortage of nurses to give bedside care, and the graduate 
who gives up private duty to administer anesthetics is 
not vacating a place that another will fill, but probably 
only wishes to get away from the disagreeable features of 
some private cases. It is a vicious circle. The causes arise 
in the modern way of living. These conditions emanate 
from society, and only by a thorough purging and cleans¬ 
ing of society can a cure take place. By restoring discipline 
to the schools and the homes, by establishing self-denial, 
quietness and self-control, by insistence on universal labor 
in a useful form and abolition of non-essential jobs, the 
balance of society will return speedily. Nurses do not 
require the same salary as men, who look forward to main¬ 
taining a home and office, therefore a nurse anesthetist 
gladly accepts a staff position at a fixed salary, with 
maintenance, and gives full time service. However, the 
prospect of a long service with desirable living condi¬ 
tions and noteworthy increase of salary is small. But 
the time of preparation is short, the responsibility slight, 
since there must be a doctor in charge of the department, 
and the escape from the bedside care most welcome, 
No nurse can honestly claim that she is a capable anes¬ 
thetist, although she may never have had any accidents, 
because she has not been tested out under all conditions. 
The nurse studies a very meager outline of anatomy and 
physiology. She cannot really know the processes caused 


THE ANESTHETIC NURSE 


55 


by the inhalation of gas, ether, or chloroform, in the 
nervous and circulatory systems. She cannot order a 
hypo, or other form of stimulation, nor examine the 
heart and lungs beforehand. She has doubtless a quicker 
intuition, deeper sympathy with some patients, and of 
course practically no interest in the surgical procedure 
except correlated to her own job. However, before a 
jury, no matter what the law, the case of a hospital 
presents a more favorable aspect, when a patient died 
under the anesthetic administered by a doctor than if by 
a nurse. The policy of a hospital employing graduate 
nurses as anesthetists should be clearly stated in its 
annual report, so that the public might know what to 
expect. In such matters of life and death, the option 
must always be given the public. It is possible that, 
while a nurse gladly takes a position as anesthetist at 
$100 per month and maintenance, the rate charged by 
the hospital to the patients, ranging from $5 to $15, is 
sufficient to net the institution a tidy balance to its credit. 
The presence of nurse anesthetists calls for special tact 
in the operating-room supervisor, in adjusting their rela¬ 
tion to the pupils, whom it is hard for them not to order 
about. The constant impinging by nurses and others on 
the outlying fields of medicine is one cause of the condi¬ 
tion first mentioned, the decrease in the number of 
physicians as compared with the needs of the population. 

2. Pupil Nurses .—The pupil nurse must not be ex¬ 
ploited, by being allowed to give even a few drops of 
chloroform to an obstetric case. The last drop is the 
one that killed. To be, all through one’s training, horror- 
stricken or calloused from a death is too big a risk. A 
practising physician can always be found, if not an intern. 
The bedside care of patients is probabb shirked where 
nurses are moved out of their place to give anesthetics, 
examine urine, etc. Anesthetics do not come under the 
curriculum provided by the legislature for nurses. Nurses 
themselves would not want it if being operated on. 

Oxygen for Stimulation. —This may conveniently be 


56 


THE OPERATING ROOM 


stored in small tanks lifted with one hand, and standing 
in low tripods like the nitrous oxid tanks. Large oxygen 
tanks are a more sure reserve, but can only be rolled from 
place to place (first removing the fixture). To administer 
oxygen properly is not difficult, but it is the source of many 
mistakes that can be avoided. 

1. Gage , bought at any instrument house, screwed on, 
when the nozzle for the fixtures is taken off—a dial, 
which, when opened, shows how many pounds’ pressure 
remain in the tank. All oxygen tanks in the hospital 
should be regularly tested, and there should be a fixed 
number of full tanks in reserve in a fixed place, according 
to the bed capacity of the institution. The oxygen weighs 
nothing. A pupil can tell by no means but the gage 
whether a tank is full or empty, without wasting gas. 
But it expands with a pushing strength of 250 pounds in 
the largest size for hospital consumption. 

2. Fixtures. —On the tank hangs a bottle of clear glass 
containing water which must be constantly changed to be 
fresh and clean. Through the rubber cork go two bent 
glass tubes. The tube running down the lower must he 
under water. It is the one connected with the tank, and 
the oxygen must be forced through this water because: 

(a) A leak can be detected when the tank is not 

in use, 

(b) The gas is moistened and rendered more fit 

to breathe, 

(c) The speed of the flow in administering is reg¬ 

ulated—at the rate of three visible bubbles 

uniformly showing. 

The shorter tube is connected to the patient. If this is 
reversed, the water will be blown all over the place and 
the gas wasted. 

3. Cost. —By applying the gage before and after ad¬ 
ministering oxygen, the amount may be estimated and 
charged to the patient. 

4. Mouth- and Nose-pieces. —A small catheter of rubber 
well lubricated except in the eye, or specially made flat 


THE ANESTHETIC NURSE 


57 


black rubber tips which fit the nostril, are best for stimu¬ 
lation. A rectal injection needs a black enema tip. These 
fixtures must be washed and disinfected so as not to trans¬ 
mit the pneumococcus or tubercle bacillus. The funnel 
method is not effectual, as can be shown by a lighted match, 
flaring up with intensity because the gas rises to the ceiling. 

Special Anesthetics. —A. Spinal anesthesia, perhaps not 
more than a dangerous, fascinating experiment, requires 
a special outfit. The strictest asepsis, if such can be, is 
needed, on account of tapping the cord and injecting a 
foreign substance. With private patients the surgeons 
have their choice of anesthetic depending on their diag¬ 
nosis. The cost is borne by the patient, usually. With 
ward patients, no fads are allowed, and the scope of this 
department is determined by the medical board with 
whom rests the credit of the institution. An error in the 
choice of anesthetic should lead to a careful investigation. 
Spinal anesthesia is an exact duplicate of lumbar puncture 
as far as the preparation goes. The fluid to be intro¬ 
duced (without any force but gravity) is a chemical sub¬ 
stance, innocuous to heart and kidneys in the normal in¬ 
dividual, while chloroform is injurious to one and ether 
to the other, in many cases. Hence this substance, 
stovain, was chosen when it seemed unsafe to use the 
others. A small sterile glass is used into which are emptied 
the ampules of stovain, whence it is poured into the glass 
tube specially made, graduated, for introduction into the 
cord. This procedure usually takes place in the operating 
room, though the anesthetic nurse attends the physician 
anesthetist, who is chosen for an added skill in lumbar 
punctures. The patient is stripped to the waist of his 
loose operating garb, and sits on the table, leaning for¬ 
ward, with his arms resting on the shoulders of a shorter 
person standing close to him, so as to bow out his back 
at the lumbar region. The area is cleansed with iodin 
and alcohol, then the spinal fluid drawn off. It is not 
required for examination or measurement usually. To 
the same needle is connected the stovain tube, held very 


58 


THE OPERATING ROOM 


close and low to show the presence of spinal fluid, to 
which the anesthetic is now added, without introducing 
any air, then the tube is raised to a normal position. The 
patient’s eyes are covered. His sensation is tested from 
the toes up to the point selected for incision. When com¬ 
plete anesthesia up to the desired point is obtained, the 
patient is laid on the table in the position indicated, and 
the operation begun, during which he can converse freely 
with the surgeon, who asks frequently about his sensations. 
Sometimes this anesthetic has proved fatal, while in other 
instances it has been ideal. Syringes must be very thor¬ 
oughly cleansed with cold water after containing human 
serum, which, if cooked, ruins their smoothness of action. 

B. Rectal Anesthesia .—The Gwathmey enema is given 
by the anesthetic nurse, at an exact moment, co-ordinating 
with the surgeon’s preparatory moves. Formula: For 
every 75 pounds of patient, 

Ether 5j, 

Olive oil 5iij. 

This is mixed in an enamel graduate. In a basin, neatly 
covered, stand 

Funnel, 

Rubber tubing, 

Glass connecting tube with one tapering point, 

Large male catheter lubricated, 

Artery clamp. 

The entire amount is not always absorbed in the 
rectum. After operation the residue is siphoned off and 
measured, followed by a flushing with cool water and soap¬ 
suds. During the operation the patient’s face is covered 
so that he may rebreathe what he eliminates, which 
promptly begins after injection. The advantages claimed 
for rectal anesthesia are: 

(1) Smoother process, 

(2) Reduction of vomiting, 

(3) Freedom for surgery of head or neck. 

C. Local Anesthesia .—This is desirable for eye, ear, 
nose, throat, teeth, spine, circumscribed wounds for 


THE ANESTHETIC NURSE 


59 


small tumors, etc., and minor accidents. Varietjr of 
opinion about purity and strength depending on the age 
of solutions renders the tablet method the happier. Each 
hospital should have its own formulary, covering minutiae 
of hypodermic preparation. When a local reliable phar¬ 
macy supplies the hospital, its staff may prepare solu¬ 
tions. The surgeon orders a preparation made on a 
percentage basis, for example, “Inject 5 minims of 4 per 
cent, cocain solution.” Women are, as a rule, not reliable 
in arithmetic. This weakness is made worse by hurry or 
strain. Hence the solution should be made for them, so 
that they may have only to measure the minims. For 
the sake of the patient, all such things should be fool¬ 
proof. No supervisor should take it for granted that hypos 
are correctly calculated. The nurse must solve the prob¬ 
lem on paper and get the supervisor’s 0. K. There must 
be distinct printed rules about boiling or not boiling drugs. 
Wholesale laboratories make tablets with strict hygienic 
care. 

I. Cocain comes under the Harrison Law in New York 
State, with which nurses should be familiar, therefore it 
should be framed in every corridor. This drug is smuggled 
in enormous quantities and introduced to young school 
children so as to form the habit early. Nurses should 
study this social menace and throw themselves heavily 
on the opposite side, proving by example that they 
realize and try to offset it. For example, after a minor 
operation in a home, where the drug is paid for by the 
patient, the nurse should show the unused portion to the 
doctor and destroy it. He is not entitled to it, because 
he has not to report to the state for what he does not buy. 
She is not entitled to it, because she did not pay for it and 
is not obliged to provide any drug at any- time. Cocain 
should be not only limited but abhorred. The operating- 
room supervisor should not resent having to travel for 
her supply to some central distributing point, such as, 

(1) Superintendent of nurses, 

(2) Pharmacist of the hospital, 


60 


THE OPERATING ROOM 


as these are the only persons holding licenses whom the 
law would permit to hold it. There should never be an 
atom of cocain left lying about. 

II. Novocain is a synthetic preparation, not habit¬ 
forming and not related to cocain, though the name was 
made on account of the similarity in anesthetic effect. It 
is less toxic than the other substitutes for cocain. When 
injected, it exerts a powerful, prompt, but not sustained 
anesthetic action, which last may be remedied by the 
addition of adrenalin just before injecting. 

III. Quinin and urea hydrochlorid may be used in 
“anoci-association” in combination with novocain, thereby 
diminishing the required amount, and, consequently, the 
ill effects of both. It may be purchased in ampules. 
It is very satisfactory following operations for hemor¬ 
rhoids or fistula in ano. 

General History of Anesthesia: 

Dr. Crawford W. Long gave ether in Georgia, 1842. 

Dr. Wells gave nitrous oxid gas in dentistry, 1844. 

Dr. Morton, Boston, gave ether in 1846, very generally. 

Dr. Jackson. 

Sir James Simpson gave chloroform to Queen Victoria 
in 1847 for childbirth. 

Classes of Anesthesia: 

1. General: Absence of sensation and consciousness 
(ether and chloroform). 

2. Local: Absence of sensation in the site of one 
nerve only—but patient conscious (novocain). 

3. Regional: Absence of sensation in a large portion 
of the body—but patient conscious—two or more nerves 
involved (stovain). 

Preparation for General Anesthesia: 

Standard preparation: 

Field of operation and surrounding area. 

Intestinal tract—purgative usually the day before, 
and one low S. S. enema. 

Stomach—stomach empty—no solid food 8(?) 
hours previously, no liquids; 4(?) hours. 


THE ANESTHETIC NURSE 


61 


Urine—examined. 

Mouth—thoroughly cleansed with boric acid. 

False teeth, et al., removed. 

The anesthetist must make a thorough examination of 
heart and lungs, as to toleration of anesthetics, and 
makes a special point of gaining the patient’s confi¬ 
dence. 

Methods: 

I. Open—ether and air mixed, 95 : 5 (Fig. 59, p. 359). 

II. Closed—all ether (Fig. 58, p. 359). 

To give ether by the open method, use the mask, and 
the drop method, i.e., one continuous dropping, saturating 
different parts of the gauze equally—never hurry it—give 
the patient all the time he wants, e. g., having him count 
and blow the ether away. A special art is required in 
handling children. 

Three stages: 

1. Excitement. 

2. Anesthesia suitable for operation. 

Not rigid, but relaxed, 

Not conscious, but capable of coming to soon after 
ether is withdrawn. 

3. Profound narcosis, very deep anesthesia followed by 
death. 

In the first stage the breathing and pulse are irregular, 
and the reflexes are increased, i. e., the pupils are dilated; 
muscles are rigid. 

In the second stage (the sympathetic), breathing is 
regular, pulse rapid and regular, reflexes are diminished 
or absent, pupils are normal in size and do not change on 
exposure to light. 

In the third stage—we do not w T ant to arrive at this 
stage—the anesthetist should discontinue the anesthetic— 
the pupils are again widely dilated, and the patient is 
dying. 

Patients must never be anesthetized alone on account 
of unforeseen conditions in the first stage. 


62 


THE OPERATING ROOM 


General addenda: 

1. Chloroform may produce death by cardiac paralysis. 

Ether, by paralysis of respiration. 

2. Ether preceded by nitrous oxid gas is the more 
rapid method. 

3. Anesthesia is used merely for muscular relaxation 
for accurate surgical diagnosis. 

4. Nitrous oxid causes a condition similar to asphyxia, 
therefore the breathing must be watched rather more than 
the pulse. The patient may laugh or cry hysterically 
afterward, but otherwise has only malaise. 

5. Most surgeons for lengthy general anesthesia desire 
the hypodermic injection of morphin + atropin because: 
1, The patient has less excitement “going under”; 2, 
and is less sensible of pain “coming out.” 

6. Chloroform and ether are inhaled. Novocain is in¬ 
jected subcutaneously; cocain may be 

Painted on—in varying strengths, 

Dropped in the eye, 

Injected by hypo. 

7. The pulmotor (Fig. 9) requires skill and care in 
cleaning, especially in not confusing the parts and 
closing off the wrong channels, but anyone can learn to 
operate it, “for resuscitation of the apparently lifeless 
from the effects of anesthesia, poisonous gases, smoke, 
drowning, electricity, collapse from any cause. The 
operator applies the face mask and turns a key, starting 
the mechanism of the apparatus, to produce immediate 
and measured respiration, with pure oxygen entering the 
lungs at each inhalation. The tongue is held forward by 
forceps, and oxygen prevented from entering the esopha¬ 
gus by pressure with the right hand” (Da Costa, Modern 
Surgery). 

8. Pus basins for vomitus should have one high outer 
wall. 

9. When the anesthetist uses a table, it must be set 
to place at once, and a high stool given him, immediately 
after the patient touches the table or is wheeled in on it. 


THE ANESTHETIC NURSE 


63 



10. Ether must not be introduced near a flame, match, 
lamp, pilot light in gas range, or room containing gas that 
absentmindedly might be used. 

11. Cost is not the factor determining where to buy 
ether, but quality. Similarly with chloroform. Both 
deteriorate on exposure to air, and must be bought in 
containers as small as possible: 

(a) Ether, J pound cans, 

(b) Chloroform, 40 grams. 


Fig. 9.—The pulmotor. 

In beginning a new case, the anesthetist should 
open new bottles. 

To carry it on, some use the left overs from the 
day’s previous cases. 

Otherwise, all left overs may be used for cleaning 
grease marks, in two stock jars. 

12. Chloroform masks may be covered with flannel, 
because anything more open of mesh will permit drops to 
fall through and burn. The flannel, being boiled for each 
using, must soon be removed. 








64 


THE OPERATING ROOM 


13. There should he strict economy and accounting of 
both gases, chloroform and ether; none should be taken 
for personal use. A ratio of the amount used for 

Each type of operation, 

Each anesthetist or surgeon, 

Each anesthetic nurse’s term 
is worth compiling to induce thrift. The hospital stat¬ 
istician should demand it. 

14. Each nurse on this service should keep a record of 
the types of anesthesia in which she assists, so as to 
appraise her experience. 

15. She watches for hemorrhages. 

16. She is taught to sponge out mucus. 

17. She administers amyl nitrite p. r. n. by breaking 
the new fashioned lint tubes or the former pearls. 

18. She learns artificial respiration—keeping slowed 
down to 16 strokes to the minute. A nurse may dis¬ 
tinguish herself doing this in an accident or drowning at 
any beach. 

19. She learns how to hold the jaws to prevent a patient 
from swallowing his tongue—downward and back, prac¬ 
tising on the family skeleton. 

20. There are odd minutes when the industrious nurse 
is waiting with her patient for the anesthetist, when she 
may make hundreds of yards of packing (Fig. 10). 

21. Before she is moved up to the third service, suture 
nurse, she may help clean instruments after cases and 
learn what each is, how used, and how put together, or 
may clean those that are taken away by their owner 
daily. 

22. Ether caps may be made from towels (Fig. 8) and 
put on fresh if disarranged during operation. 

23. For gas-oxygen (Fig. 5) and novocain, the patient’s 
knees are strapped to the table with a wide soft band. 

24. For goiter operations the head of the patient is 
lowered and soft pads of fluffed towels dropped in curves 
of neck to hold up the laparotomy sheet. 

25. Gas-oxygen anesthesia is usually charged to the 


THE ANESTHETIC NURSE 


65 


patient and the nurse checks off the amount if the bill is 
to be estimated by “pounds” used. 

26. The actual isolated task of any one sort is not hard, 
but the nurse must be ready at all times for an instan- 


~1 



Fig. 10.—Making packing from a bandage. 

taneous complete change of front, with presence of mind 
which can be cultivated only by trying to foresee what 
may happen. 

5 



66 


THE OPERATING ROOM 


Return of a Patient to Bed. —In some systems the 
anesthetic nurse accompanies the patient to the ward, 
and goes over her thoroughly from top to toe, to prove 
to the pupil nurse that she has delivered her uncon¬ 
scious charge in good condition—cap, chest blanket, dry 
gown, abdominal and T binder, bandages, drains, stock¬ 
ings, general review of skin, pulse, respiration. The chart 
is brought down with the patient, having a slip fastened 
to it, containing in red ink the important details of the 
operation for the immediate enlightenment of the ward 
nurse , who can then proceed intelligently in the post¬ 
operative care. This slip is modeled from the following: 

Surgeon—Bryan. 

Patient—Coolidge. 

Operation—Appendectomy. 

Stimulation—Strychnin, gr. 1/30 by hypo. 

Drainage—Two rubber, one cigarette. 

Intern—Jones. 

The ward nurse copies this on the chart bedside note at 
once. 

When the patient is put to bed, clean, warm, dry, with 
positive assurance that there are no hot-water bottles forgotten 
concealed in it, or a rubber drawsheet previously super¬ 
heated which may cause a burn on the back when sensa¬ 
tion is diminished and vitality lowered by anesthetics, 
the operating-room pupil collects her basins, towels, 
blankets, etc., and returns to prepare them for the next 
case (boiling face articles). She should warn the ward 
nurse about possibility of hemorrhage or shock. Tonsil 
cases are laid face downward on the stretcher (arms 
above the head, face slightly turned for air) in order to 
swallow no blood. Some surgeons keep drainage appendix 
cases on their face also, with good results. The time is 
well spent in giving the ward nurse all possible information 
regarding the postoperative condition of each case. 

Recovery Room. —This is rather infrequently made an 
adjunct of the operating suite. If the patient has special 
nurses, the operating-room staff is not greatly incon- 


THE ANESTHETIC NURSE 


67 


venienced. If the recovery room has its own workroom, 
there will be no jostling at critical moments to both staffs, 
at hoppers and heaters. If the hospital is very small, 
private and exclusively surgical, the equipment may be 
planned so as to bulk largely around the recovery room. 
Noise from postoperatives should be kept out of the range 
of convalescents. If the hospital is a very large, general 
private and ward institution, the skyscraper plan is ideal, 
permitting splendid grouping of cases in stages. The crit¬ 
ical postoperative ward case may be dropped one floor 
only per elevator, to a ward service out of earshot of con¬ 
valescents, yet sufficiently near the operating plant to get 
hot blankets, sterile water, etc., quickly. The skyscraper 
admits of loggias and common windows on all sides of any 
corridor, so that the private patient retains his room till 
departure. The ward convalescent may be placed else¬ 
where. The interns operating may not attend post¬ 
operative cases, hence the recovery service is handed to 
others. There should be a distinct line of cleavage in the 
nursing service also, siuce the time of an operating-room 
pupil is worth vastly more than that of ward pupils. 
Supposing the recovery room stiff included in the operat¬ 
ing-room suite the equipment following must be provided: 

1. Murphy Drip .—Protect patient with soft old blan¬ 
kets, four at least, so folded that they break in the center 
and merely overlap. Fold each in half, laterally, and 
lay two over abdomen and two over knees. Catch to¬ 
gether with two safety-pins. This admits the apparatus 
and the nurse’s hand, without hoisting covers and chilling 
the patient. The drip should be arranged as follows: 
tank, source of heat (electric-heating element, bulb, or 
hot-water bag), drop apparatus (clamp, cord, bent hairpin, 
special glass connecting tube), tubing in two parts, special 
thermometer as for infusions, with outer glass tube, to 
test just before injection, small bit of rubber catheter, 
solution ordered, plain water, glucose, or saline. Murphy 
drips given wrongly are worse than useless. Any nurse 
should be able to improvise and also to demonstrate the 


68 


THE OPERATING ROOM 


Murphy drip, including the follow-up work of pulse 
report, perspiration, urine, absorption, residue, etc. 

2. Gatch Bed .—Of these, any surgical service should 
have about 50 per cent, of its beds. They are needed for 
drainage and heart cases. They may be improvised by: 
Back-rest or straight chair, rubber-covered pillow to sit 
on, small board under pillow, very long sheet folded diag¬ 
onally into a sling fastened at the head of the bed frame 
to make the seat, many pillows of assorted sizes for 
rest of arms and back, second long sling with folded sheet 
for foot rest, pillows under knees. All pillows used below 
chin must be rubber covered. Raise foot of bed an inch 
if necessary. 

3. Lavage requires careful report of findings, measuring, 
etc. 

4. Bladder Drainage .—Patient lies on face and bed is 
specially made as follows: Head and foot of a three- 
sectional mattress used, four thin rubber-covered hair 
pillows substituted in center, arranged longitudinally, 
bandaged into position, retention catheter drops down 
between two pairs of pillows into a urinal tied to the spring. 
This may be used for helpless fat fracture cases to slip 
bed-pan in the space required, saving purchase of ex¬ 
pensive bed. 


CHAPTER IV 


THE SUTURE NURSE 

“Watching over Israel, slumbers not, nor sleeps.” 

Problems of the Personnel.—In small hospitals which 
find difficulty in procuring interns, the suture nurse com¬ 
bines the duties of an instrument passing intern with her 
own, and actually takes part in the operation, her gloves 
being smeared with blood, and her hand forming contact 
with the wound and then with her table, which is, therefore, 
not sterile. It seems difficult for many to understand asep¬ 
sis, and we have to believe what they say till we see them 
make a break, whereas if every person in the operating 
unit were asked to demonstrate asepsis, the results would 
be amazing. If a suture nurse receives one instrument 
from the operator, she should rescrub (with new gar¬ 
ments) for another case. If she has absolutely no con¬ 
tact per glove, arm, gown or utensil, with the operator or 
patient, she does not need to rescrub. Careful statistics 
may be made covering the suture shift of several nurses 
to find which is the best of the many methods used. No 
two hospitals seem exactly alike, and it is these many 
marked differences which cause acute annoyance and 
tension during the frequent changes of personnel that fill 
the history of small hospitals. In the small hospital the 
number of pupils may be raised to the standard quota 
just during the hours of operating by drawing from the 
ward force. The pupil may be taught each step by the 
supervisor in class with charts, moving pictures, and par¬ 
ticularly a little dissection of poultry, etc., in the required 
region, so as to acquit herself creditably, and so that the 
surgeon is not aware of shifting personnel unless he 
peers very closely at her masked figure. If the hospital 
has a good system of posting cases the night before, the 
69 


70 


THE OPERATING ROOM 


head nurse can hold a class at 6 p. m. Where a hospital is 
classed A. and has a registered training-school, there must 
be in the school all told the proper quota of pupils to 
arrange the schedule to admit a clean suture nurse. We 
are interested only in schools of the academic type, which 
pride themselves in teaching future operating-room super¬ 
visors to attend thousands of patients yet to come. 

Suture Nurse.—She has fewer but much more exacting 
duties assigned her than the others. It is the last shift of 
a hard service, with intense concentration, superheated 
and humid atmosphere, unyielding floors, sometimes un¬ 
pleasant dovetailing into the tasks of others, with the 
immense responsibility of life and death. A nurse in this 
position must save herself, keep good hours, wear suitable 
shoes, and attend closely to personal hygiene and diet to 
maintain stout resistance and a clear head. Her every 
act is under close scrutiny. The surgeon will decide if 
she has the makings of a future supervisor. Onlookers 
may request her name to file for future use for an out-of- 
town institution. The pupils will try to see if she makes a 
“break” in asepsis. She should bear herself seriously 
alongside a patient that is hovering on the borderline be¬ 
tween life and death. She is largely responsible for pre¬ 
vention of mistakes among the rest of the unit. Even 
a new intern should receive her hints graciously. Routine 
kills originality, but saves time and gives security. The 
suture nurse should learn and demonstrate routine pro¬ 
cedures so long that the staff feel it is ingrained in her 
system and then flirt with it once in a while by showing 
some clever feature to suit a special case, or else “we’ll 
never get on.” There should be no conversation except 
by the doctors. Simple signs are enough to obtain assist¬ 
ance of any sort from the other pupils, few in number, 
and standardized in all hospitals if possible. The atten¬ 
tion of the suture nurse should be focused on the wound 
and operative procedure, not on any person, then the 
case will never lag. Orders given for postoperative care, 
diagnosis, explanation of procedure, indications to the 


THE SUTURE NURSE 


71 


intern for first dressings, call for stimulation, etc., may 
then be distinctly understood. Frowns, coughs, agitated 
hand waving, etc., are taboo. There are many tender 
points to adjudicate in the field of the scrubbed nurse. 
No secret numerous caucuses of two will solve the prob¬ 
lem. The following are important conditions: 

1. A surgeon wishing to do superexcellent work may 
lean heavily on the help from a graduate nurse working 
constantly with him and instantly anticipating all his 
wishes. “What’s sauce for the goose is sauce for the 
gander.” Any privileges of the operating room which 
cannot be allowed to all ward attendings should not be 
allowed to any. As for 'private cases, a hospital might 
within the bounds of reason employ a graduate nurse on 
a regular salary and then charge the patients for her 
assistance- for certain men’s cases if they care to avail 
themselves of her skill. This will dampen the ardor of 
the type who partake of the nature of that bird, the cuckoo, 
which lives in other birds’ nests. 

2. A supervisor who is told by the surgeon to scrub for 
his case, when it is not the custom to do so for all cases, 
is within her rights to ask as soon as possible for an 
understanding of her duties. A fresh interpretation is 
undoubtedly necessary. She may weakly accede to his 
request if she likes better to be hobbled to a suture table 
than to be chasing dirt, and correcting nurses, but she is 
not earning her pay as “supervisor.” 

3. A pupil who is not allowed to scrub for ward cases is 
within her rights to ask for a readjustment as soon as 
possible, so that she may show her ability. 

4. A superintendent of nurses who is asked to judge these 
cases may ask for a fair trial of the pupil, preceded by 
proper instruction, on some average cases. Then if the 
pupil is stupid, one who has already succeeded on the 
suture shift should be sent back to relieve for that period. 

There should be open, free discussion, with all the 
different factors represented. In professional matters, a 
Board of Governors can always obtain an unbiased 


72 


THE OPERATING ROOM 


opinion from some celebrated hospital consultant. When 
a surgeon accepts the position of ward attending, he 
tacitly accepts the professional duty of teaching pupils, 
and he cannot justly debar nurses from scrubbing for 
ward cases in the routine prescribed, without specified 
charges that have to be accepted as sufficient by the 
Training-school Committee if need be. The operating 
room is manned and equipped from funds obtained by 
taxation, and chartered by the legislature, both proc¬ 
esses based on the best customs of government. Similarly 
the legislature deputes a Board of Regents to carry on a 
system of education in this arena. It is contrary to the 
principles of the systems of America for any one to 
Throw sand in the ball bearings, 

Throw a monkey wrench in the cogwheels, 
by changing the main methods for his personal benefit 
and trampling on the rights and feelings of others. The 
other surgeons will feel that this “bloc” is an aspersion 
on the quality of their work. To withdraw instruction or 
experience from pupils which they should legitimately 
expect leads to difficulty in securing good ones in future, 
hampering the workings of an institution which hopes to 
reach far into posterity by sound teaching and well- 
watched corrected experience. There is no more ludi¬ 
crous public figure than a short-sighted surgeon, who 
wants the best now, and gives no thought to the quality 
of the support he is building for himself for ten years 
hence. It is not conceivable that any man should be so 
false to his position that he would prefer to make a 
supervisor lick his boots, cringe, and obey in fear that his 
aspersions could cost her her position, while the pupil, 
intrenched in the protection of her school, has no diploma 
to lose yet, and cannot be badly hurt by his remarks 
while she is only a learner. 

Conducting an Operating Room.—The suture nurse 
learns now or never how to become a supervisor by watch¬ 
ing and assisting in the general management of the operat¬ 
ing room. This is done by (a) visiting the main offices 


THE SUTURE NURSE 


73 


with the head nurse, with requisitions, shopping for 
special equipment with her, reporting losses and break¬ 
ages, (6) relieving the head for her time off, and, if pos¬ 
sible, vacations, and (c) taking night cases alone (unless 
the hospital has a full night staff). Costs, materials, and 
makes of garments should be discussed as a part of daily 
conversation; at the desk is a spindle on which is placed 
all information regarding (a) stock running low, ( b ) 
criticisms by the surgeons, (c) instruments requested. 
Business acumen is developed only by doing business and 
learning from mistakes. 

Duties Before Operation.—All dry goods needed are 
collected on a tray in their covers, and set on a table. 
Sutures and special appliances called for, e. g., sand-bags, 
kidney bag, shoulder braces, stirrups, blankets, hot-water 
bags, are collected and placed on a stand. Instruments 
are put on to boil the required time, and brought in by 
the circulating nurse when the suture nurse has scrubbed 
and covered one table. 

Preparation of Skin at Operation.—Tincture of iodin is 
most extensively used. The strength must vary with the 
age of the patient—three-quarter strength is most common. 
Benzine removes grease from the pores, but must have 
completely evaporated, so that the iodin will penetrate. 
Harrington’s solution is favored by a few, requiring a 
gauze scrub for three minutes, then a thorough rinse of 
alcohol, before applying iodin. In hernia cases many 
use tincture of green soap and water before applying 
Harrington’s solution and iodin. In rectal and vaginal 
cases, tincture of green soap, water and bichlorid of 
mercury or tincture of iodin, one-third strength may 
be used. Irrigations of sterile salt solution are used in 
rectal cases, or bichlorid of mercury in vaginal. In scrub¬ 
bing the area of operation, the spot directly over the 
place of incision should be done first, while the sponge is 
clean; then it is carried outward, around and away, 
never going over a spot again with the same sponge, then 
the umbilicus is done last and alone, being the most un- 


74 


THE OPERATING ROOM 


clean. The sponge stick is dropped into a pail or floor 
basin, whatever is the cleanest floor receptacle from which 
the circulating nurse bends to retrieve it and boil it. The 
ward nurse should never send up a patient with a dirty 
umbilicus. Organisms thrive in the dark and warmth 
there on account of the moisture not well taken up in 
the hurried morning dip. 

Rules for Scrubbing Up and Setting Up.—The house 

has standard rules as to 
Time, 

Extent, 

Disinfectants 

in scrubbing. The nurse dons her cap and mask, then 
scrubs, then is given her gown which must have long 
sleeves, and gloves which go over the edge of the cuffs. 
For a clinic of 5 cases by one operator, she lays out 
five times as much enamel and linen material as for 
one, all at one time, being sure that there are all the 
unusual instruments needed in unusual cases. When 
setting out the goods, she wears two pair of gloves, 
peeling off the outer pair as the surgeon comes in. 
The only things to be cleansed and returned between 
cases are the instruments. The folded towels to dry 
the doctors’ hands are arranged in 5 sets of three 
between layers of sterile towels. At the beginning of 
the second case the surgeon with wet scrubbed hands 
comes to the towel table, whisks to the floor the cover, 
then takes up one, his assistants the same. She pushes 
covers from her , and stands as far as possible from the 
tables, or from the circulating nurse when bringing in the 
tray of instruments. The “straight front” learned in 
maintaining asepsis is the same posture required of a 
good waitress in serving food. 

Carrying on the Operation.—The suture nurse teaches 
by example, and works by routine not to confuse those 
beneath her in rank. After the first four scrub towels 
are clamped into place by the first assistant the suture 
nurse hands him, by its handle, the sponge stick of iodin, 


THE SUTURE NURSE 


75 


then one of alcohol, neither of which she takes back. 
She never receives anything except sterile goods brought 
in their containers by the circulating nurse. She hands 
the laparotomy sheet to the assistant, without contact, 
then the fresh towels with clamps, always having the air 
of dropping them like a hot potato, to show that she is 
afraid of touching the operating-table or anything per¬ 
taining thereto. She does not assist in draping the 
patient. She drops scalpel, clamps, ligatures, sponges, 
forceps, etc., on the small instrument tray, then goes 
back to her table. She keeps towels hot in saline, offering 
them when the intestine is about to be exposed. Usually 
these “towels” are large tape sponges with heavy rings 
attached. She never touches the outstretched hand of 
the junior assistant, whose duty it is to give the tra¬ 
ditional signs for “probang,” “tape,” “enough.” Watch¬ 
ing alertly over the whole field, she is responsible for the 
entire management of the case, sending for the supervisor 
when in doubt. When laid on the table in groups by a 
routine method carefully taught beforehand, the instru¬ 
ments should always form a definite picture of the steps 
in the operation. As the matter concerned is very vital, 
all work should be neat and done in a finished manner. 

When it is time to sew up, clean towels are laid around 
the wound, and the bulky instruments are sent out. 
Sutures are economically cut and counted. 

The assistants put on the dressings. One principle is 
paramount for abdominal work—the laying on of adhesive 
begins at the pubis to check hernia and proceeds upward 
(similarly the braiding of the many-tailed binders). “A 
slight bowing or looseness is added on each strip, not to 
do aw r ay with the pressure for hemorrhage and union, 
but to take into consideration a reasonably expected 
distention. All the dressing must be covered with ad¬ 
hesive, so as to permit no gateway of infection .”—Trained 
Nurse and Hospital Review. 

The suture nurse may proceed to put away clean things 
no longer needed in their containers—rubber tissue, 


76 


THE OPERATING ROOM 


tubing, silkworm-gut, etc.—and to lay out the supplies 
for the second case, in order of use, iodin, sponge stick, 
etc. It is a great advantage in time saving and smooth¬ 
ness to have her remain clean. She acts like the pivot 
on which a squad turns. 

Changes of Surgeon.—If a different surgeon is posted, 
there is an entire change. The suture nurse scrubs, dons 
new garments, and sets up with new table covers. The 
circulating nurse cleans the table (if it is stationary) and 
removes all table covers, basins, etc. 

Records.—The clerical work relating to a case record 
should be done by the suture nurse, under the super¬ 
vision of the head nurse. Data regarding specimens, 
drains, operator, anesthetist, anesthetic, et al., which 
might at any time be referred to in study of case histories 
or in a court inquiry, must be truly and wholly set 
down. 

Specimens.—These are put in the required solution 
(4 per cent, formalin) and marked with the name of 
surgeon, patient, tentative diagnosis, dates, and part 
affected, and sent to a specified shelf in the laboratory 
by a responsible person. Findings play a large part in 
demonstrating skill in diagnosis, checking needless or 
careless operating. They must be included in the pa¬ 
tient’s chart. 

Instruments.—In the best operating rooms usually the 
instruments are selected by a committee of surgeons. All 
purchases must be made in a systematic way after re¬ 
jecting old instruments and hearing special requests from 
progressive men. The ward attending surgeons are en¬ 
titled to the best. The committee should keep an 
inventory and personally audit it at regular intervals. 
Cabinets should be locked and opened only by responsible 
persons. The committee, consulting with the supervisor, 
should aim: 

To give good service to all surgeons (within reason), 
To have enough instruments to run off big clinics 
in as many rooms as are equipped for operating, 


THE SUTURE NURSE 


77 


To keep the whole stock (operating, ward, and 
obstetric) in good repair. 

Instruments should be named according to their pur¬ 
pose rather than for their inventor. 

There is a routine channel in many institutions to send 
old instruments from the operating room to the wards 
and then to the missionaries. Owing to the large deficit 
all good hospitals have, it is hardly fair to expect the 
missionaries to say “Thank you.” The suture nurse should 
collect all instruments for repair, sharpening or renick¬ 
eling, and pack them for mailing, knives in their boxes 
which are not to be lost, scissors in last weeks’ return of 
soft paper, and all listed as to: 

Length, maker, use, number, and special repair 
required. 

One slip goes with them, one is kept in the main office by 
the bookkeeper as a check, but the original list is made 
in the instrument book, which must never be destroyed, 
because: 

(1) It is a check on the stock book or inventory, 

(2) It shows how certain models stand wear or not. 

This collection for repairs includes: 

Operating room, 

Wards, 

Obstetric service, 

Ambulance bags, 

Accident room. 

A ward or other service must not be crippled by sending 
away instruments; they must be replaced by those from 
the main operating room and the reserve drawn on for it. 
Two of one kind need not be sent at one time. The 
committee only can discard instruments permanently, 
listing them with their original values, so as to make a 
requisition on the Board for their equivalent. Books of 
addresses of dealers are much needed. Catalogs of 
manufacturers furnish material for interesting and in¬ 
structive study in their illustrations and nomenclature. 
The suture nurse should become deft at sharpening com- 


'78 


THE OPERATING ROOM 


moner instruments with strop, hone, or oilstone. She 
tests all for sharpness, rust, bite, or spring. A drumhead 
made of the wrist of an old soft kid glove drawn over an 
embroidery hoop or napkin ring is excellent for testing 
edges. If it cuts with snappy vigor the edge is sharp. 
If it saws like dough, it is dull. Instruments after 
operation are rinsed, boiled, scrubbed with Bon ami, 
washed in tincture of green soap and water, then rinsed, 
then plunged in alcohol and dried, and put away in 
order. 

Ambulance Bags.—Unless the ambulance service has its 
own graduate nurse, supplies can all be unified, and a 
small stock may go farther by making all of it work, if 
the bags are sent to the operating room to be replenished 
and instantly returned, in good condition. The special 
emergency equipment for them is as follows: Hypodermic 
set, small oxygen tank, tourniquet, obstetric tape, 
vaginal and other packing. 

Supplies Made by Pupils.—The suture nurse being 
senior, has charge of plaster work, discussed in another 
chapter, and dismissed herewith, “Have them right, for 
if they’re bad, they’re very bad, and so is the surgeon’s 
humor.” A man with a bent arm after fracture attacks 
the surgeon who set it, who cannot take refuge in “bad 
bandages.” Cutting gauze may be left to orderlies or 
porters if machines are used. Apportioning piles of gauze 
to workers outside the operating room requires patterns, 
counts, and inspection. Rolling muslin bandages, making 
dressing-covers, and the general cleaning by maids all 
come under the suture nurse as a learner, while the super¬ 
visor is on, and as a charge nurse at such times as Sundays, 
night, and vacations. In making supplies a huge store of 
goods sterilized and not, should be maintained, and moved 
forward to be used, putting the newer away. Sterile 
goods do not remain so indefinitely. There are four con¬ 
ditions that must be met: 

(1) The every-day supply for all services, op., 
ward, obs., etc., 


THE SUTURE NURSE 


79 


(2) A reserve of sterilized goods, on a fixed written 

standard, 

(3) A HUGE reserve of unsterile goods made up as 

sponges, cotton balls, dressing-covers, etc. 

(4) A supply of gauze and cotton, flannel and mus¬ 

lin, crinoline, and outing flannel. 

The supervisor should teach that the operating room is 
ready for anything that may happen, such as: 

(1) A breakdown in the sterilizers or engineering 

department, 

(2) An unusual run of pus cases, cholecystec¬ 

tomies, etc., 

(3) An epidemic among the nurses, 

(4) A visitation from God, such as the Japanese 

earthquake, floods, or fires. 

Needles.—The points of needles require constant test¬ 
ing, before and after each boiling and when putting away 
at night. Never boil a dull needle. Never hand a sur¬ 
geon a dull needle. Keep a large stock (as far as is 
compatible with the climate). Needles may be threaded 
with silk and drawn into gauze before boiling, or they 
may be dry sterilized in flannel. Perforated nickel 
boxes (4 x 2 x 1J) may be used to boil needles in for 
safety as to 

Number, 

Care of points, 

Care of nurse’s fingers. 

Hypodermic needles made of platinum do not cost 
very much, yet they last forever. Each individual should 
have his own, especially for anesthesia. 

Surgeons’ needles are round bodied, full curved, with 
cutting points. No. 2 is used for through-and-through 
or for stay (retention) sutures with silkworm-gut or heavy 
silk. Number 19 is used for cleft palate, with silk or 
linen, and for a fine skin suture with silk, horsehair, or 
fine silkworm-gut. It has a patent eye. 

Hagedorn needles are flat bodied, with cutting points, 
and full curved, half-curved, or straight. Number 1 is 


80 


THE OPERATING ROOM 


used for through-and-through sutures, No. 12 for fine skin 
work and circumcisions, straight for blood-counts. 

Sims’ cervix needles are half-curved with cutting points, 
suited for trachelorrhaphy and abdominal hysterectomy. 

Mayo needles are full curved with flat shank, square eye 
and round point, suitable for catgut in peritoneum and 
fascia, or wherever a heavy round-pointed needle is needed. 

Lister’s fishhook has a cutting point, used in the cervix 
with catgut. 

Ferguson’s needles are full curved, round pointed, used 
intra-abdominally in fascia and peritoneum. 

Ferguson’s taper-pointed needles are for intestinal work 
with silk, linen, or catgut. 

Kelly needles are full curved, round point, long eye, 
mostly for abdominal work. 

Intestinal needles are straight, round bodied, like a 
common cambric or embroidery needle. 

Milliners’ needles are somewhat larger, but similar. 

Curved intestinal needles are used to advantage. 

Emmett needles have a taper point. 

Blunt needles are round, full curved, with blunt end, for 
herniotomy. 

Mayo intestinal needles are shaped like a fishhook, and 
are used with fine silkworm, linen, or catgut. 

General Notes on Needles.—Needles are expensive and 
should be sharpened to use again. Thej^ should be 
counted by the suture nurse before the close of the case, 
and if all are not accounted for, a search made and all 
other work suspended. Once out of her hands, the needles 
may be dropped in a sheet or a bloody sponge. Everyone 
participating should keep all sorts of goods in place, and 
pay attention to the faint gleam of any bit of metal or 
glass in unusual quarters. The suture nurse is responsible 
for where things aren’t. Cutting points are used on 
tough tissue (skin, cervix). Round points are for delicate 
parts (eye, intestine), as they tear less. The self-threading 
patent needle (calyx) has a spring eye where the thread is 
drawn in from the end. 


THE SUTURE NURSE 


81 


Sutures (needle and thread) must be studied with care 
in four ways: 

L Locations: 

1. Head, scalp, face, inside mouth or nose or ear, 

2. Skin—face, hand, foot, 

3. Bone—joints, 

4. Mucous membrane—inner lip, gut, 

5. Deep abdominal—peritoneum, fascia, 

6. Cervix, 

7. Perineum, etc. 

II. Future condition: 

1. Absorbable—becoming one with the tissue 

itself. 

2. Non-absorbable, as catgut: 

(а) Never removed—in gastro-enterostomy so 

as to be sure to hold, as silk, 

(б) Removable after a definite period, after 

union is known to be established, as silk¬ 
worm-gut. 

III. Pattern of stitch—how taken in the flesh, how run in, 

and how cut, as through and through, running, 
interrupted, etc. 

IV. Material—silk, linen, wire, etc. 

The suture nurse, following the operator, must try to 
remember what he did on a similar previous case, what the 
supervisor taught in the morning rehearsal, and knowing 
the point at issue, will judge from rules what she would 
use herself. By training 
Memory, 

Judgment by deduction, 

Observation 
she will not often err. 

I. Locations .—Location of wound in the scalp means 
that the needle must be stout, fairly large, with a sharp¬ 
cutting point for the tough tissue, and that the thread 
must correspond in stoutness. The wound must knit 
securely, on account of the exposure of the part to the 
elements, to violence and to infection. Hence a non- 
6 


82 


THE OPERATING ROOM 


absorbable, removable thread, such as silkworm-gut. The 
nurse can deduce for herself, by applying her knowl¬ 
edge of anatomy. The face must be handled gingerly 
for the cosmetic effect. In an accident case of this sort, 
give the patient a mirror to see that his dressing is neat, 
and after removal of sutures, to show the minuteness and 
paleness of the scar. There will not likely be strain or 
human violence, hence a slender thread; there must be 
no scar, if possible, and we should not destroy needlessly 
any tissues, hence a fine needle. The nurse gives a round 
bodied very fine curved needle, with fine silk to be re¬ 
moved. In most cases a straight needle is good on curved 
surfaces and a curved needle on straight surfaces, outside 
the body. 

II. Future Condition .—For deep abdominal work, with 
no future outlet, i. e., a permanently buried suture, the 
nurse must perceive that it must not hurt or irritate the 
surrounding tissues, therefore it should be either absorbed 
into the tissues or walled off. A deeply buried suture of 
silkworm-gut will not absorb, but irritate, prevent healing, 
and cause a sinus. Hence the material offered should be 
silk, which will not irritate, hardened catgut, or linen, 
according to the surgeon’s preference. It stands to reason 
that a soft suture made from animals, which becomes 
merged into the flesh in a few days, will not be so firm in 
uniting as a stout thread which must come out, and for 
which the wound must wait much longer. In the per¬ 
ineum which is subjected to great strain at stool, the 
sutures should be of non-absorbable material, such as 
silkworm-gut (even silver wire). In deep abdominal work, 
where irritation is to be avoided, and yet there will be 
strain, owing to distention or expulsive efforts, hardened 
or chromicized catgut may do, which is so treated that 
it cannot merge into the surrounding tissues for ten, 
twenty, or forty days as labeled. The larger the number, 
the longer it takes to absorb, and just so much longer 
time is given the cut to heal. Loose bits must not be left 
in a cavity—they act like a foreign body, or irritant. A 


THE SUTURE NURSE 


83 


special condition like infection, preceding operation, 
changes the technic somewhat. 

III. Pattern of suture: 

Guy. —Temporarily put in with a long loop for traction 
in place of using vulsella. 

Lembert. —In and out at one side of the intestine, 
skipping the wound, and in and out, through skin on the 
other side. 

Through-and-through. —Stout silk or silkworm-gut on 
long, heavy curved needle through the skin and deeper 
layers at once (but not the peritoneum). 

Tier. —Each layer by itself: 

(а) Peritoneum—fine catgut on small needle, 

full curve, round body. 

(б) Deep muscle—chromic gut, interrupted. 

(c) Deep fascia—catgut. 

(< d ) Skin—catgut, silk, gut, clips, or adhesive 
only. 

Buried. —Never to be visible again; in deeper layers and 
not involving the skin; capable of absorption. 

Running. —One thread inserted several times without 
cutting (basting). 

Interrupted. —Knotted and cut at each insertion. 

Tension. —A very long suture beginning several inches 
beyond the wound and passing through the skin and 
deeper layers. 

Continuous. —See Running. 

Purse-string. —A silk suture in the intestinal tract, on a 
straight fine needle all the way around in both directions, 
and poking in or burying the raw flesh, like gathering the 
top of a bag, then tying securely—to invaginate a raw 
area ( e. g. } the stump of the appendix. 

IV. Materials: 

Silk is the most common intestinal suture. It may be 
used in the heaviest sizes for deep ties and for tractors. It 
comes in two colors, black and white, braided and twisted, 
on spools or small cards. The standard time of boiling 
is five minutes. It should not be used in infected areas. 


84 


THE OPERATING ROOM 


Linen is used largely like silk, for intestinal sutures, 
being a vegetable product and capable of boiling for 
ten minutes. It comes in two colors and four sizes. 
During operation it is dropped in a sterile cup of water 
to keep flexible. 

Pagenstecher or celluloid linen comes fine, medium, and 
heavy. It is the ideal non-absorbable suture material, 
possessing all the advantages of silk, in being strong, 
easily tied and securely fastened, of uniform caliber and 
stiff, while more easily threaded than silk even when wet. 
Being a vegetable product it has less capillarity, and this 
to some extent prevents infection from passing along the 
thread (intestinal sutures even when taken with the 
greatest care, commonly include part of the mucous 
membrane). Pagenstecher is stronger than silk, hence 
the longer boiling, which will not weaken it. Both are 
taken off cards, wound on gauze, and boiled in the bite 
of sponge forceps. 

Silkworm-gut comes in two colors, white and black, 
iron-dyed, and in three thicknesses, fine, medium, coarse. 
It is common fishing gut, prepared from silk when it is in 
condition to spin, but not yet spun. It is an ideal, smooth, 
strong, non-absorbable, non-porous suture material, soft¬ 
ened by boiling, which renders it less difficult to tie. Used 
dry, it is too hard and brittle to tie. Iron-dyed silkworm- 
gut is more antiseptic. Silkworm-gut may be used as a 
stay suture, carried in very deep, through the-skin and 
perineal muscles; but must be removed. It may be boiled 
repeatedly and kept in alcohol. 

Horsehair possesses the advantages of silkworm-gut 
and is better, in that its elasticity prevents the cutting of 
tissues. It is the ideal material for mastoids, but not for a 
tender area such as the lip. White is used on negroes and 
black on Caucasians. 

Ligatures .—The nurse should keep new stock and test 
all. For ligating deep vessels use plain catgut, coarse or 
fine, according to the size and importance of the vessels. 
The surgeon limbers up the ligature by winding it three 


THE SUTURE NURSE 


85 


times around his warm hand. They must be cut long 
enough to hold in the firm grip of any sized hand. For 
coaptation of parts a more slowly absorbing gut (i. e., 
chromic) is good—delayed union is strongest. For out¬ 
side work (skin) noil-absorbable ligatures (silk on a wart) 
are used. 

Making Catgut.—A hospital may employ graduate 
nurses or other technicians to make catgut, and procure 
at great cost the equipment suitable. However, as the 
making of catgut is not going to be a part of bedside 
care in the nurse’s future work, and as pupils have none 
too much time in three years to become sufficiently adept 
at the latter, it seems absurd to employ their time for 
that purpose. Furthermore, the placing of blame for 
failure (infection) would become, it is highly probable, 
focused on the pupils, and, being something not usually 
proved or disproved, a source of resentment—never- 
ending. Again, should a nurse, after being graduated, 
choose some such occupation as catgut-making (can you 
imagine it?) she would have to begin at the bottom of the 
processes of the institution she chooses to work in. More 
and more closely the schools are trying to follow the 
curriculum laid down by the State Boards, without 
adding to or taking therefrom. It is hoped that the 
remedy for the old breach of faith which led hospitals to 
exploit pupils will quickly show results in a finer type of 
nurse who will be the more devoted to duty for the stronger 
protection she is now receiving. 

General Addenda: 

1. Be sure to lubricate specula (vaginal, rectal) with K. Y. 

2. All thick heavy metal must be thoroughly cooled in 
a deep basin of sterile water. 

3. Slides, smear glasses, etc., for specimens are kept in 
their own basin apart, but sterile. 

4. It is an art to wind an applicator 

(а) Fluffy at the end, 

(б) Easily stripped after with a cotton pledget, 

(c) End of metal buried, so as not to inflict a 

wound. 


86 


THE OPERATING ROOM 


5. A weighted speculum can.be improvised by hanging 
a quart pail of water to the Sims. 

6. Practise taking special instruments entirely to 
pieces and putting them together again without any parts 
left over , especially the screws in the handle of a tonsil 
snare, releasing the rod in which the wires are caught, also 
the tonsillotome; otherwise they will never be cleaned. 

7. A left-handed nurse must reverse her gestures for 
a right-handed surgeon. A right-handed nurse must do 
so for a left-handed surgeon. 

8. The suture nurse should instantly know who owns 
an instrument, according to the surgeon’s or the hos¬ 
pital’s inventory, by 

(a) Its maker, 

(b) Its style, 

(c) Its age and condition, 

(d) Markings, 

(e) Numbers. 

9. The numbers and other markings on clamps aid in 
pairing the parts after cleaning. 

10. Use instruments to work with at the sterile table. 

11. When the surgeon says, “There is one sponge back 
of these sutures,” do not let him forget it. 

12. Bee that the patient is sent down in good, clean 
shape, being washed, dried, rubbed with alcohol and 
powdered before application of binder, looking for bruises 
or burns from iodin, which easily happens if some runs 
down beneath the buttocks where the pressure is great. 
Report to surgeon if found, chart, and show to ward 
nurse. 

13. Speed is the essence of the operation. Anticipate 
the surgeon’s wants. 

14. Large abdominal retractors must be moderately 
warmed to 100° F. to prevent shock. 

15. Hand solutions too hot annoy the surgeon, impede 
his progress, and make solutions irritating. 

16. Irrigating solutions should pass at the lower end 
through an infusion thermometer (encased in a patent 


THE SUTURE NURSE 


87 


glass connecting tube) to show the temperature on 
administering. 

17. For a neat skin dressing chloroform seals rubber 
tissue in place. 

18. Saline has certain advantages when used to dis¬ 
solve drugs for local anesthesia (cocain, novocain, etc.): 

(а) It is stimulating, 

(б) It increases blood-pressure, 

(c) It aids absorption. 

19. Finger-cots should be generously supplied at the 
times indicated. 

20. In bone surgery (Fig. 11) the circulating nurse 
washes and boils each instrument every time it is used— 
this causes the operation to be slower than others. 




Fig. 11.—Lane’s bone plates, steel, for femur, for use in fractures 
of bone. 

21. Electric apparatus must not be boiled, especially 
all the ° ‘scopes” and bone transplantation instruments 
(selected) (Fig. 12). 

22. While waiting for the patient to be adjusted, those 
scrubbed up may cover gloves with sterile towel. 

23. Solutions in hand basins are covered with sterile 
towel till required. 

24. All instruments used for amputating and resecting 
are discarded (and boiled again, p. r. n.). 

25. Data should and can be compiled regarding the 
use and wear on gloves, suture material, ether, etc., for 
the hospital office. 

26. Extravagance in cutting sutures and ligatures makes 



88 


THE OPERATING ROOM 


the surgeon tremble. It is a bad omen for the nurse’s 
future, if he thinks of her assisting him when he would 
be the provider. Some firms make short lengths of catgut 
to save waste, every inch representing the life of animals, 
the labor of experts, testing and marketing at great cost. 
Unfortunately the hospital has an atmosphere of indirect 
responsibility concerning costs, nurses never seeing the 
persons who foot the bills, Mr. Doe and Mr. Taxpayer. 



Fig. 12.—The Albee electro-operative bone set. 


27. The Lovell needle is built like a ligature carrier, 
specially devised to sew around the hemorrhagic area 
after a tonsil operation. 

28. Small needles must be, threaded quickty. Cut 
catgut bias, and knotv the needles, whether the eye is at 
the side or back. If the nurse participates by receiving 
materials from the area of operation, she should give the 
catgut a twist or two at the eye, after threading, and it 
will lie flat. Place the needle, one-third from the eye, in 
the holder, and hand it with one bend of the wrist, laying 
the handle in his palm, the mouth pointing back to the 
nurse, who catches the thread in her fingers taut. The 



THE SUTURE NURSE 


89 


nurse should know a right-handed surgeon from a left. 
In watching some operating-room work the laws of com¬ 
mon politeness seems to have been utterly forgotten in 
such matters, leaving out the idea of service. 

29. Needles for syringes should be slip-ons, which are 
cleaner and more easily worked. They must always have 
a stylet. Special needles for spinal work have an eye, 
and the point of the stylet is beveled with the needle. 

30. Knives are right and left for throat work. If the 
edge has a full curve it “bellies.” Blades set in a frame 
(tonsillotomes) come under the classification of knives in 
general care. Paracentesis knives for myringotomy have 
a double blade and must pass through the small opening 
of the smallest ear speculum. The handle of a scalpel 
may be used for blunt dissection. The blade is used inside 
the abdomen to sever the appendix (then discarded). 
The bistoury (straight or curved) is used to open abscesses. 
The amputation knife (different sizes) is used on the ex¬ 
tremities. The phalangeal knife (shorter than the last) 
is used on the hand. A double-bladed Catling knife is 
used to prepare the soft parts for amputation. 

31. Scissors are chosen with an eye for the anatomy of 
the part and the operator’s hand. They are: 

Blunt—sharp pointed, 

Straight—curved (upward), 

Curved on the flat, right or left, 

Long—medium—short, 

Screwed together—slip apart (mortised). 

32. Forceps are selected with a view to the depth of 
the part to be treated. They are of many types: 

Straight or with handles, 

Plain or mouse-toothed, 

Pivot, screw lock, or mortise-lock, 

Smooth or corrugated, 

Corrugated crosswise or lengthwise (for rea¬ 
sons), 

Straight, angular, or with special curves, 

Of varying lengths. 


90 


THE OPERATING ROOM 


There are forceps for special organs: gall-stones, obstet¬ 
ric, placenta, gastro-enterostomy. 

An artery clamp has such an important place (to clamp 
an artery) that it should never break or come apart, 
therefore the inferior molded forceps should give way 
before the expensive but superior drop-forged instrument. 

33. Rubber tubing must be boiled and drawn over big 
clamps to prevent maceration of delicate tissues (in¬ 
testinal) . 

34. Idiosyncrasies are permissible in surgeons of skill, 
and should be noted and served; for example 

(а) Tall table for tall man, 

(б) Weight and size of gloves, 

(c) Method of sterilizing gloves, 

(d) Left handed—lost a finger, 

(e) Stools for fat men, 

(/) Manner of dressing, shoes, etc. 

35. An old table may be heightened by putting the feet 
in four pieces of iron gas pipe. 

36. Breast amputations and hysterectomies require 
many clamps. 

37. Keep a generous stock of sand-bags of assorted sizes. 

38. Many Politzer bags and plenty of rubber-dam are 
required for drainage cases by suction. 

39. When aristol is shaken on a wound, it may be wound 
with a bichlorid towel done by the circulating nurse (her 
arm in towel) (Fig. 2). 

40. When a Murphy button is used, for intestinal 
anastomosis, a very special warning is issued to the ward 
nurses and orderlies, and the button (Fig. 13) should be 
the subject of general comment till found. 

41. Pus must be closely confined to the smallest amount 
of linen, and the circulating nurse should handle it with 
forceps till it has soaked in a disinfectant. Constant pains 
must be taken to block off avenues of outgoing infection. 

42. Loose silk may be drawn into gauze before boiling. 

43. A man run over by an auto is, speaking not too 
literally, a “clean” case. His wound may be infected, 


THE SUTURE NURSE 


91 


but he would not be a menace to the operating-room. 
Yet the tetanus germ may find entrance into his blood¬ 
stream, therefore the suture nurse should listen for the 
surgeon’s first hint for an injection of antitetanus vaccine. 

44. Scissors are tested just before boiling up, on cotton. 
If the tip only makes a clean cut, well and good. Then 
try the whole blades. Look for gaping between the 
points. 



Fig. 13.—Murphy anastomosis button, round, with center collar. 

45. Artery clamps which do not work well likely are 
going to be thrown on the floor. 

46. Give the surgeon a sharp scalpel to begin with. 

47. Mortise locks must never be strained or forced 
(causes looseness). A mortise is a cleft over a bar, on the 
bias (bevel). All joints should be well wiped and oiled 
with sterile oil. 




CHAPTER V 


THE OPERATING-ROOM SUPERVISOR 

“Her price is far above rubies .”—Book of Proverbs. 


Her Status.—A. National .—A very close relation neces¬ 
sarily exists between the College of Surgeons, with its 
clearly defined scope and aims, and the sisterhood, vast 
but ill-organized, if at all, of operating-room supervisors. 
A solid footing on which they could arrange the body 
and method of their instructions could easily be given 
the nurses by the college. Surgeons have accumulated a 
large mass of heterogeneous knowledge about the care of 
edged instruments, the strength of drugs in anesthesia, 
the pathology of the operating room, et al., which could 
in a convention be condensed and grouped to teach to 
beginners. A surgeon cannot really feel sure of the results 
of his work, when the supervisor gives her own interpre¬ 
tation of his wishes to a pupil who may again give hers 
in the execution. 

B. Local .—It would be well for the Board of Directors 
to visualize what they need and to standardize all the 
features of the position of opreating-room supervisor, to 
prevent haphazard selection and hazardous results: 

1. Age—possibly thirty, not under twenty-five. 

2. Education: 

The highest to be found among nurses, plus train¬ 
ing in a recognized operating room plus special 
work in a still more famous one—possession of 
one modern foreign language. 

3. Advancement: 

Membership in suitable nurse societies, 

Reading of a thesis in such societies, 

92 


THE OPERATING-ROOM SUPERVISOR 


93 


Approved membership in some social, non-pro¬ 
fessional club, 

Subscription to journals, secular and professional, 
Visiting other operating rooms—study of exhibits, 
Attending surgeon’s lectures elsewhere. 

4. Demonstrations of methods to surgeons’ committees 
before engagement. 

5. Presentation by the operating-room supervisor’s own 
alumnae association of a special degree after a period of 
approved service (including character). 

There has not yet been sufficient incentive for nurses 
to go onward. The careful selection of women on the 
above five points would leave a comparatively small class 
eligible for appointment. In competition with other fields 
for women, hospitals demand a too closely confined con¬ 
ventual life with too small pay for the amount of brains 
and honorable sentiment required. The greater the strain, 
the fewer should be the hours. The greater the obliga¬ 
tions, the more privileges: 

Frequent short vacations, 

Pleasant suite of rooms, 

Permission to have relatives as guests, etc. 

C. The community is directly affected by the attributes 
of the operating-room supervisor, since the skill she dis¬ 
plays will or will not be reflected outside by her pupils 
as follows: 

In offices of physicians, 

In operations in private houses, 

In making and sterilizing supplies for obstetric 
cases, 

In the care of goods. 

When a small community boasts only one hospital, it is 
sometimes necessary to equip and send out a mobile 
unit for: 

Railway, automobile, or steamship accidents and 
other disasters, 

Contagious cases which cannot be admitted to the 
hospital. 


94 


THE OPERATING ROOM 


In these cases the results should be just as good as 
when the work is done inside the operating room. Fur¬ 
thermore, many cases operated on have a legal phase, 
that seriously concerns inheritance, domestic relations, or 
individual rights, hence the records kept in the register 
must be accurate and complete. 

D. Transportation by rail, auto, and airship have made 
it possible to convey many patients to large, well-equipped, 
famous operating rooms which owe not a small part of 
their subsistence to these outside sources. The operating- 
room supervisor is one of the factors in the decision of the 
patient to go or stay. If her staff is kind, industrious, and 
honest, due to her never-ending supervision , the patient 
stays. Moreover, local surgeons wish to feel that their 
nurses are equal to anything they may bring in. In 
addition, pupils trained in a small operating room which 
truly affords better opportunities for supervision, may 
have to attend some affiliated school for other subjects, 
e. g., pediatrics, or orthopedics, in which they are called 
upon to exhibit the essentials of operating-room knowledge. 
More deadly and invidious in comparison than any of 
these is that of the neighboring small town hospital eating 
off the edges of the body of the work of others. 

E. In the institution to which she belongs the operating- 
room supervisor is entitled to a place in many of its 
councils. Her work is practice rather than theory, and 
it is given a cash value. 1. The fees charged for the use 
of the operating room are fairly large, and there should be 
a monthly balance struck, showing supplies purchased, 
repairs made, maintenance, service by graduates and 
pupils, and fees received. 2. Dressings, saline, Dakin 
solution or other needs for emergency may be sold (by 
permission of the directress) if the operating-room super¬ 
visor feels that she will not be embarrassed thereby be¬ 
fore replenishing her stock, at a cost based on the features 
above named. Nothing but emergency well explained 
justifies the sale of goods, least of all, operations in private 
homes to avoid paying hospital fees. Physicians can 


THE OPERATING-ROOM SUPERVISOR 


95 


arrange to have supplies made at home. It is a pleasant 
occupation for a retired nurse. Pupils in training have all 
too little time for learning to be making supplies for out¬ 
side cases. 3. Again, inside the hospital, the operating- 
room supervisor has a special footing in the laundry, on 
account of the quick turnover necessary in goods, and the 
value of direct speech, rather than via the training-school 
office. 4. Furthermore, there is a check on careless prepa¬ 
rations in the ward, by a system of reporting, when a case 
comes up badly shaved, or with enema incomplete, to the 
directress. 

Methods of Business.—At present the National Asso¬ 
ciation of Nurses maintains a bureau at 370 Seventh Ave., 
New York City, in which nurses holding such credentials 
as described above, should file them, stating what work 
they wish. This bureau acts as a clearing-house between 
them and institutions desiring supervisors. It is a serious 
step to apply for and accept an operating room. The nurse 
should investigate as follows: 

1. The status of the hospital in the reports of the 

State inspector, 

Training-school inspector, 

College of Surgeons’ inspector. 

2. Its annual report, bed capacity, operations. 

3. Number of pupils on operating service. 

4. Personnel of nursing staff. 

5. Occupational diseases of the town. 

6. Local regulations of the hospital, 

Whether open to all in the community or closed to 
all but a selected few. 

7. Personal details: 

Regarding salary, hours of duty, relief for vaca¬ 
tions with pay, rooms, duties outside operating 
room, unnamed obligations. 

8. Terms of contract, notice due both contracting parties 
to terminate an engagement, provision for illness, etc., 
provision for graduated increase of salary for cause. 

One thing to be shunned is “one-man” appointments, or 


96 


THE OPERATING ROOM 


“one-official” pulls. It is not a healthy state of affairs 
in which a supervisor is engaged on the recommendation 
of one surgeon or one superintendent. She should apply 
openly, in competitive examination, with others, and 
should at all times present the endorsement of her own 
Alumnae Association. To be indebted to one person for 
an appointment causes partiality to him and unfairness 
to the rest. No nurse should be engaged without hunting 
up her references leisurely. No individual member of the 
Board of Directors needs to have any deep interest in 
her appointment, for a little creeping up of her salary now 
and again would provoke jealousy. Open candidacy, 
discussion by committees and investigation are the only 
safety. The nurse can easily find in any medical directory 
the history and achievements of any surgeon. To offset 
this, she should be able to show what is thought of her by 

1. Her own equals, the alumnae. 

2. Her state (registration). 

3. Her former employers (hospital). 

4. Her professional critics (former surgeons). 

It is the unvarying rule of some hospitals never to 
take on an official temporarily “out of a job,” which, 
though it has its exceptions, in the main works out rather 
well. Boards of Directors, when looking to commercial 
registries to provide staff nurses, take a big risk which is 
unnecessary, in view of the reliability of the professional 
clearing-house at 370 Seventh Ave., New York, and the 
safety of communication through the Modern Hospital 
and other journals of accredited management. 

Errors in Appointments.—A. Inbreeding ruins stamina 
and initiative. Small hospitals would be wise to look for 
supervisors from larger schools, and to advise their own 
graduates to take subordinate positions in large hospitals 
before launching out as heads. Inbreeding is disastrous 
to stock, speaking in an agricultural sense. If a small 
group of surgeons know 90 per cent, of all that is to be 
known in surgery, they can teach only 30 per cent. Their 
pupils absorb only 70 per cent. Were these promoted as 


THE OPERATING-ROOM SUPERVISOR 


97 


supervisors, they could teach only 60 per cent. The 
second generation of pupils would absorb only 50 per 
cent. Thus in only one cycle exactly 50 per cent, of 
surgical knowledge would be lost beyond recall to that 
hospital. Furthermore, familiarity breeds contempt. A 
stranger does better in a position of rank. “A prophet is 
not without honor, save in his own country and among his 
own people.” 

B. When the stranger is appointed, she should fall into 
her allotted groove, work and observe, teach the methods 
that were there before her, and make no changes on her 
own initiative. When she has been informed by the 
Surgeon’s Committee that she has, in their estimation, 
passed a successful probation, she may then offer to them 
suggestions not to be acted on without their consent. It 
is not a sufficient reason that “we do it this way in our 
school,” to institute changes. She should make the new 
position “ours,” and not refer to the old. In institutional 
work the life of nurses is in such a constant state of flux 
that surgeons usually become callous, skeptical, or in¬ 
different to anything but the drudgery of essentials. They 
succeed long before and long after each appointment. 
Each new nurse should show deference to their magnitude 
and obtrude her personality as little as possible. 

C. All questions of prerogative and priority among 
surgeons must be referred to the Surgeon’s Committee. 
Lack of punctuality on beginning, overrunning time pre¬ 
scribed, posting cases on another man’s day, etc., are 
problems that do not lie within the supervisor’s juris¬ 
diction. They may interfere with the smooth running 
of her work. She may inform anyone in authority (the 
Committee of Surgeons or the directress of nurses) of 
the obstacles to her work, but she cannot decide an 
issue. 

Personality of the Supervisor.—There are things which 
cannot be written down in an application, but show in the 
wear, which yet may be more fruitful of good than aca¬ 
demic qualifications: 

7 


98 


THE OPERATING ROOM 


1. A good sound physique and a rather practical, calm 
mind. {Mens sana in cor pore sano.) 

2. Determination, ability to plan and carry out a sys¬ 
tem, presence of mind. 

3. Dignity and aloofness. 

4. Searching knowledge of human nature, generosity, 
tolerance of faults, good principles always lived up to. 

5. Powers of discipline, impartiality, devotion to duty. 

6. Sympathy with the sick, especially emergencies, and 
particularly willing service then. 

7. Breadth of experience and wide observation both of 
things professional and extramural. 

She should be not the showy assistant of a surgeon 
before the gallery, but first, last, and always the nurse of 
the patient, and the teacher of the pupils. 

A Thing Greatly to Be Desired.—The curriculum of the 
Board of Regents specifies no details of just what shall 
make up operating-room training. Text-books hitherto 
have not dealt with that field. It would be perhaps not 
impractical to have examinations held every three to 
five years under the auspices of the College of Surgeons 
based on the knowledge necessary for nurses to execute 
their aims in unifying operating-room methods, and ex¬ 
pediting work and safe-guarding everybody concerned. 
This would actually mean the granting and regular re¬ 
newal of licenses by the College for supervisors. This 
examination might run as follows: 

1. Presentation of records of character, skill, and 
executive ability. 

2. Written papers on newer materia medica, methods of 
disinfection, anatomy, etc. 

3. Preparation of pupils to be suture, anesthetic, apd 
circulating nurses for various types of cases. 

4. Demonstrations of aseptic technic, making dressings, 
making solutions. 

5. Physical and mental tests. 

If the examiners are surgeons and nurses in the van of 
their professions, this will tone up the whole service. 


THE OPERATING-ROOM SUPERVISOR 


99 


Teaching.—A. No one need ever say that the reasoning 
powers are not brought into play in nursing. Girls are 
notoriously weak in arithmetic, knowing which, the 
operating-room supervisor must teach the principles of 
arithmetic soundly to her pupils all the time, and never 
take anything for granted. This should be a fixed custom. 
For every solution to be estimated, the pupil should work 
out the problem on paper and present it for the super¬ 
visor’s O. K. before handling the drug. A few types are 
given below. 

Stock —Bichlorid of mercury tablets marked grs. viiss. 
Solution of 6 quarts. 

Strength 1 : 6000 required. 

1 tablet to 1 pint (sterile) water = 1 : 1000 

solution. 

1 tablet to 6 pints (sterile) water = 1 : 6000 

solution. 
= l of the 
strength 
or six 
times as 
weak. 

Stock —Lysol, pure (100 per cent.). Solution of 4 quarts of 
1 per cent, solution required. 

5 j to 1 pint (sterile) water = 1 per cent, solution. 
5 j or 3 viij to 8 pints (4 quarts) (sterile) water — 
solution required. 

Stock —Silver nitrate tablets grs. v. Solution of'l pint of 
1 per cent, solution required. 

Sj of any pure drug = 480 grs. (round numbers 
500, approximately). 

grs. v of drug = 5/500 (5/480) or 1/100 or 1 per 
cent, of an ounce. 

grs. v of drug in 5j (sterile) water = 1 per cent, 
solution. 

16 ounces = 1 pint. 

16 times grs. v of drug (or 80 grs.) in 1 pint of 
sterile water = 1 per cent, solution. 


100 


THE OPERATING ROOM 


Stock —Morphin sulphate, gr. J. Hypo, ordered, gr. £. 

Dosage by hypo, in arm requires amount from 8 
to 20 minims. Choose a common multiple of 
4 and 6—not the least common multiple 
always , but one suitable for size of dose by 
hypo, in arm. 

Factors of 4 are 2 and 2. 

Factors of 6 are 2 and 3. 

Multiple must contain two twice and three 
once = 12. 

Dissolve gr. J in 12 minims sterile water, with 
usual aseptic technic. 

If, then, gr. \ is contained in those. 12ttr 

then, pro rata, gr. 1 is contained in 4 times 12ttjj=48ttjj 
and hence, pro rata, gr. f is contained in | of 48 tt 8v& 

12tt e — 8n^ = 4 minims. 

Draw up the whole 12 minims to syringe where it 
can be measured. Expel air and 4 minims. Give 8 
minims. 

House rules on solutions should be framed and kept 
clear. 

In teaching arithmetic, the supervisor should keep a 
collection of all data requiring such adjustment in a book 
for that purpose, and hammer at it incessantly till each 
new pupil is familiar with this rule of three as applied 
to drugs. 

B. Anatomy teaching is also essential. This is taught 
by charts, drawings, and dissection, in that order. The 
chart prepares the pupil for what to expect. A drawing 
corrects errors in her mind. If she draws the part, her 
knowledge is built up and supplemented. The dissection 
of a small liver, a chicken’s heart, or lungs, a beef tongue, 
etc., will give the lesson more point than anything else. 
The teacher explains the abnormality or accident, the 
pupil suggests (with help) the remedy, and the teacher 
points out what instruments and dressings are best suited 
for the operation. Moving pictures of similar operations 
are very helpful, because they can be arrested so that the 



THE OPERATING-ROOM SUPERVISOR 


101 


pupil sees the surgeon’s hand better than in life, and the 
array of materials he is using. 

With our present lax methods in all forms of education, 
the lack of discipline makes it difficult for hospitals to 
set a higher standard of living than is found outside, but 
if a pupil shows ignorance of anatomy and materia medica 
she should be sent back to the lower grades. Nurses are 
so keen to have operating room that this may be used 
by the teacher of junior anatomy as a powerful incentive 
to study. Cards of samples, instrument catalogs, and the 
instruments themselves should be laid out so that the 
pupils may reason out which are most suited to the parts. 
Classes should be held in precise form as in college, with 
perfect preparation by the teacher and perfect attention 
from the pupils. Notes are taken and inspected, forming 
the nucleus of a text-book when the pupil may be a head 
nurse. Data are memorized and every possible con¬ 
tingency anticipated, otherwise some unexpected change 
or request will seem about as pleasant as the stalling of 
a motor in an aeroplane. 

C. Demonstrations .— In a brief form the supervisor 
must list, demonstrate to, and see demonstrated by the 
pupils every act they shall perform during this service. 
The equipment is always there. There are many moments 
or lulls. Each nurse’s card bears the same list. She 
0. K.’s each point when she executes it and again as the 
pupil does it. 


1. Dusting, 7. 

2. Binders, 8. 

3. Opening sterile 9. 

packages, 10 

4. Scrubbing up, 11. 

5. Setting up, 12. 

6. Opening a sterile 

towel, 

D. Nursing Care .—The nursing spirit usually burns low 
in the operating room. It needs fanning. This can be 
done by: 


Making saline, 
Draping patients, 
Conducting cases, 
Running sterilizers, 
Folding linen, 
Passing sponges and 
ligatures. 


102 


THE OPERATING ROOM 


1. Sending pupils to relieve on the wards on Sundays. 

2. Conferring frequently with ward head nurses about 
the departure and arrival of operating-room nurses with 
patients—the ward nurse should inspect binder and gown 
before releasing them. 

3. Watching and teaching to prevent 

Burns, with confined iodin, 

Bruises, leaning on ether case, 

Poisoning by overdose of bichlorid, 

Paralysis by too long Trendelenburg. 

4. Sending pupils to study the progress of the cases 
they had, as to drainage, primary union, removal of 
packing as specified. 

5. Specially caring for administration of hypos.— 
charting where given and by whom , to focus blame (if 
abscess). 

6. Observing the conventions just the same as if the 
patient were conscious: 

(а) Orderly absent when women are operated on, 

(б) Also in genito-urinary cases if nurses are 

present, 

(c) Guard on all conversation, 

(d) Colored physicians absent in gynecologic 

clinics of white patients, 

(e) Patients properly draped, and sheets not care¬ 

lessly whisked off. 

7. Inspection of all cases before going to their beds. 

E. Economy: 

(1) Unnecessary expense comes from destruction 

of goods: 

(а) Oil ruins rubber bags, 

(б) Lemon juice eats enamel and porcelain, 

(c) Chloroform dissolves and eats fine tissue. 

(2) Ends and pieces may be used to advantage in 

another form: 

(a) Bandages make packing in odd minutes, 

(b) Edges of gauze folds make stuffing for 

pads, 


THE OPERATING-ROOM SUPERVISOR 


103 


(c) Catgut is saved by carefully estimating 

what is needed, 

(d) By special planning, gauze can be cut so 

that all is used, the original fold at the 
side being left intact. 

(3) Prevention of stains by quick washing length¬ 

ens the life of cloth. The laundry people 
will buy sulphuric acid at their own expense 
to bleach, rather than go without it, in the 
hospital effort to save cloth fiber. Blood is 
removed by cold water soak, or paste of 
laundry starch. 

(4) Good goods, carefully bought, will last better 

than cheap, and give better results, besides 
costing less in the end, if handled right. 

F. Wisdom in buying: 

(1) Comparison of textures. Samples of gauze 

from different firms show number of threads 
to the inch, fineness of threads, number of 
yards to the pound, evenness of run, etc. 

(2) Receiving goods and inspection of same before 

paying for them. 

(3) Comparison with other hospitals. 

(4) Study of advertisements. 

(5) Information from military and naval hospitals. 

The buyer for the hospital will probably bring pressure 

to bear on the operating room to take a cheaper grade of 
gauze, cotton, rubber, ether, etc. It is probably within 
the surgeon's sphere entirely to decide whether gauze is 
sufficiently absorbent, but the pupils may find it takes too 
long to make it up—it is sleazy, uneven, and thin. Cotton 
may be friable, rough, lumpy, dirty, or containing burrs. 
Rubber may be very malodorous and brittle (made out of 
ancient automobile tires). Instruments may be ill-fitting 
and badly plated, delaying a case or the clean-up. The 
pupils should keep tab on all goods, and all opinions ex¬ 
pressed by men while operating, who shed as they go 
down to the street the annoyances that they thought so 


104 


THE OPERATING ROOM 


big in the stress of work. How the patient fares under 
long used good ethdr is a sufficient reason for not changing. 

G. Repairs .—Missing instruments should be traced or 
paid for, and it is possible to trace the loser if the head 
nurse is watchful. (See under Suture Nurse.) 

H. Discipline .—Decorum is maintained in the whole 
suite. Proper dress, plain coiffure, absence of rouge and 
jewelry of every sort (especially rings), strict personal 
hygiene are essential. Forwardness, quarreling, noisiness, 
etc., should lead to degradation in rank on the first 
offence. Chaff and banter when a patient is waiting for 
the anesthetist are unsympathetic. There are perfectly 
fair penalties to impose: 

(а) Partial loss of time off for laziness, 

(б) Repeating work till well done at sacrifice of 

required time, 

(c) Regular report to superintendent of nurses, 

(d) Return to ward service if dull, or undesirable, 

(e) Recitations, loss of cap, sending to isolation, 

etc., according to degree, 

(/) Sending to Coventry (no intercourse with other 
pupils). 

It is poor policy to keep a poor pupil, for each year it is 
harder to dismiss her. 

I. Prevention of Infections .—The worst disgrace that 
can be endured in a hospital is an infection in an operated 
case—hernia, eye, perineorrhaphy, bone case, etc. The 
supervisor is working with six hands which she cannot 
wash, i. e., the pupil’s hands. She requires enormous will 
power to project into their minds, to charge them with 
her own force, to keep clean. She requires, besides, a sixth 
sense, the uncanny power of knowing what folks are at 
when she isn’t there, which makes some youngsters call 
their teacher “four-eyes.” By being absolutely honest 
toward her work herself in all its aspects, and by wishing 
frightfully hard that they may be also, she may get the 
desired effects. But prevention of dishonesty is im¬ 
perative, also unjust suspicion is very dangerous. Hence 


THE OPERATING-ROOM SUPERVISOR 


105 


the supervisor must be a live wire, constantly on the move, 
never luxuriating in long, quiet chats with someone. It 
will make her hair gray faster than the other nurses, but 
the institution will become famous. Not only should the 
nurses scrub thoroughly, but they must keep to clean 
places, and boil or steam goods the required time. If a 
nurse breaks a rule about the temperature of hot-water 
bags during probation, she will likely develop no finer 
moral sense before she comes to the operating room. The 
supervisor must anticipate, fear and prevent. Care must 
be exercised with masks, mouth-washes, suits, etc., among 
the whole staff. 

A check should be exercised on the orderlies. Many of 
them are the flotsam and jetsam of the world. Others 
are devoted attaches, but it is necessary to know that 
they are clean and free from disease. 

J. Self-reliance .—Night work, relief work, substitution 
in vacation all form a good school for self-reliance. Most 
pupils do excellently when left temporarily to their own 
resources. Notebooks of house rules, and movies or 
charts of typed cases may be used. The leading-strings 
must be removed early, as with infants. When going 
off duty daily the supervisor should sketch what will 
likely happen. 

Inspection: 

I. Rounds are made for daily cleanliness: 

(a) Instruments, etc., of suture nurse, 

(b) Anesthesia outfit, 

(c) General dusting by circulating nurse, 

(i d ) Cleaning of floors by orderly, 

(e) Engineering equipment put in order early— 
requests in early, 

(/) Reports and time-slips to directress of nurses. 

II. Weekly or semiweekly rounds are made with the 
directress of nurses, who observes nurses’ industry 
and demeanor, condition of equipment, attitude of 
doctors, and condition of patients. If nurses seem 
worn, examination by physician. 


106 


THE OPERATING ROOM 


III. Inventory is taken at regular intervals to keep check 

on valuable goods. 

IV. Semi-annual rounds with the superintendent, for 

painting or plastering. 

Preparedness: 

I. A generous stock of filled covers of gauze and cotton 
in circulation on the wards (if there are not ward 
sterilizers). 

II. A generous stock of every kind for the operating room. 

III. A big reserve of sterile goods. 

IV. A big reserve of goods done up, but not sterilized. 

V. A store of gauze, cotton, muslin, flannel, raw plaster, 

etc. 

There are reasons for this reserve: 

I. The old-fashioned maddening dearth of everything on 
Sunday. 

II. A big disaster in the city. 

III. An epidemic among the nurses eligible for operating 

room. 

IV. A breakdown of sterilizers. 

The night supervisor should be free to use all the 
supplies she needs, on rendering a report of instruments, 
saline, or dressings taken. 

The operating-room supervisor should visit the wards 
to see if gauze is wasted, and keep an estimate of how 
much is needed by a big drainage case. 

State Laws.—A. In New York State, under the Harri¬ 
son law, an accurate account of all narcotics must be 
kept. This is getting the cart before the horse, because 
it puts a duty on decent people, but as nurses gladly 
assist their government in its moral aims, the records are 
kept well. However, it is hoped that something may be 
done to prevent cocain from being smuggled and handled 
freely by the wrong people. A report must also be made 
of stimulants, denatured alcohol, and radium. The 
operating-room nurse, being more mature and informed, 
can see why, in this generation, it is dangerous to leave 
such things about carelessly. 


THE OPERATING-ROOM SUPERVISOR 


107 


B. The staff must take part in frequent fire drills. 
Fire in the vicinity of an etherized patient is too awful to 
contemplate. The equipment of extinguishers, axes and 
saws, hose and fire alarms should be used at regular inter¬ 
vals by all the pupils. Assignment of each pupil to a 
post should be a part of her service in each of the three 
shifts. Blankets and stretchers belong to the orderly. 
Closing of windows and doors, protection of hair and 
lungs, etc., all are included and form no insignificant part 
of the fire code as it should be observed in every building 
today, according to state regulations. In case of fire the 
operating-room register should be saved. 

Health of Pupils.—(1) Style of shoe is an important 
item on the unresilient floors, depending on the ortho¬ 
pedic surgeon’s advice to those who have undue trouble. 
(2) Bichlorid rashes must be avoided, usually by using 
the brush no higher than the wrists. Nightly dressings of 
lanolin have been thought best if they do occur. Drying 
the hands thoroughly with absorbent towels is very 
necessary. Nurses must rinse soap off thoroughly before 
immersion. Soap causes with bichlorid a black scale, then 
a fissure. A dash of hand lotion after operation helps 
keep fit. Dutch cleanser is a powerful irritant to some 
skins, also washing soda, alcohol, and ammonia. Fresh 
air, few if any late leaves, little walking, and early retiring 
make for better health during the operating service. 

Statistics.—The head nurse should make a study of the 
time consumed by each surgeon for each type of case, so 
as to help the Committee of Surgeons to adjust problems 
relating to booking operations. The length of time re¬ 
quired by each pupil to set up and clean up should be 
investigated and shaved down by practice and correc¬ 
tion. The number of instruments used by different sur¬ 
geons, if recorded, makes a ground for using up large 
spaces of time in after cleaning. Sizes of gloves for 
different surgeons and interns are entered for reference. 
Special whims regarding materials and methods will 
gradually diminish, owing to the concerted effort of the 


108 


THE OPERATING ROOM 


College of Surgeons toward simplification, barring the 
actual proved benefit of any one thing, the loss of which 
cramps an operator, and barring the destruction of orig¬ 
inality. The patient’s chart contains, for the use of the 
ward nurse who immediately begins to carry on, a concise 
report of the operation. Some time within twenty-four 
hours the assisting intern adds on a sheet specially for 
that purpose the history of the operation in its entirety. 

Academic View of the Supervisor.—Though referred to 
in other relations elsewhere, it must be noticed here that 
a supervisor oversees, and as such, must be higher than 
the workers among instruments. The unconscionably Jong 
list of duties, with their corresponding breadth, which 
are laid upon her, render it impossible to chain her to the 
leg of a suture table, from which she cannot see and know 
what is going on in workrooms, supply rooms, or wards. 
Any ordinary pupil who has successfully passed first year 
tests can be taught to be a good suture nurse, 

(1) Because she naturally wants to please the 

surgeon, 

(2) She is keyed up higher than on the wards, 

(3) She has rehearsed it successfully to the super¬ 

visor before 8 a. m. 

To make a humble comparison in domestic affairs, the 
chatelaine of a mansion on Fifth Avenue is a first-class 
housekeeper, but she does not assume the duties of a 
waitress and send the maid engaged for such a purpose to 
oversee the work of others. The supervisor should be 
engaged, in the first contract, not as the handmaid of any 
one “difficult” surgeon, but as head of the operating suite, 
and capable of putting her knowledge and skill into her 
workers, so that the praise they earn means tenfold for 
her. It is a lazy mental habit which causes the head to 
scrub, giving behind sterile intrenchments vague dis¬ 
connected orders that far from ensure sound honest work 
behind the scenes. It is also a jealous mind, usually, that 
leads the head to scrub and remain in the pleasant at¬ 
mosphere of the operating room, with the surgeons, to 


THE OPERATING-ROOM SUPERVISOR 109 

which the pupils are remarkably sensitive, since their 
chance for development is destroyed. From the stand¬ 
point of the surgeons, while they are serving worthily 
as attendings, not the least of the many benefits they 
bring the institution is that of developing talent for the 
future among the nurses. “To scrub or not to scrub, that 
is the question,” which should have a recognized inter¬ 
pretation by having the Training-school Committee, 
Committee of Surgeons, and directress enunciate a policy 
that is written into the contract for supervisors. It needs 
no shrewdness to note that the supervisor who likes to 
scrub would probably never wet her fingers if placed 
temporarily on a ward. The surgeons who teach nurses 
will be rewarded by enthusiastic devotion. All the features 
of the operating room form the keys and stops of a big 
pipe organ, on which the supervisor can bring forth no 
harmonies if she chooses only to work the bellows. 

Summary.—It can readily be inferred that the super¬ 
visor requires alertness, suavity, self-control, a fine but 
not dominating sensitiveness, optimism, shrewd powers of 
appraisal of men’s motives, a well-defined plan for her 
own future, and her windows open to the outside world. 
Such a woman needs intensive recreation, no night duty, 
and strong support from others f concerned in training 
understudies and future heads. The winner of deathless 
fame in the hospital world is she who from the back¬ 
ground reproduces in hundreds of pupils her own skill and 
honesty. 

MODEL OF LESSON BY OPERATING-ROOM SUPERVISOR 

8.45 a. m. : Nephrectomy—lumbar route. 

This is to bring out the points of difference between the 
case in hand and others. 

The supervisor demonstrates to the suture nurse and 
circulating nurse. The anesthetic nurse is the patient. 

7.45 to 8.00 a. m. 

Required .—Works of reference on gross anatomy, 
minute anatomy, surgery, materia medica, cinemato- 


110 


THE OPERATING ROOM 


graph, charts, mannikin, skeleton, notebooks and pencils, 
a text-book on operating-room procedures for pupils, 
chalk, blackboard, patient's chart, x-ray, history, patho¬ 
logic findings, diagnosis, marking of diseased kidney, film 
of a nephrectomy, this route, instruments, towels and 
other (unsterile) paraphernalia for this special operation, 
table easily adjusted for kidney position and wheeled in 
(patient kept outside on it at first), kidney bag, pillow. 
A pair of kidneys on a tray from the diet kitchen. 

Remarks. —May be necessary to resect a rib (not often). 

Lumbar route avoids cutting peritoneum. 

Only one cut needed—kidney not connected with any¬ 
thing above—to extirpate, while to extirpate the uterus 
there are three (two tubes and cervix). 

Important to patient to retain one good sewer (never to 
take out the last remaining kidney, nor the well one). 

Demonstration. —Patient “etherized" outside, put in 
position, wheeled in. 

Stripped, examined, marked kidney corresponds with 
pathologist’s findings, x-ray, etc. 

Draped with towels, lap sheet, etc. 

Instruments arranged as per movie, participants close in. 

Supervisor shows incision, varying in length with 
stature of subject, quantity of fat around kidney—com¬ 
pare with chart to show relation of skin, muscle, kidney, 
and peritoneum. 

Shows delivery, clamp, ligation, walling off, amputa¬ 
tion (by drawing or on pair of real kidneys). 

Counting sponges, needles, etc., before closing. 

Dressings, adhesive, binder, clean up, stretcher. 

Emphasize seriousness of hemorrhage if renal artery is 
cut, and fatal result if it is on good kidney. 


CHAPTER VI 


THE MAIN OPERATING ROOM 

Planning.—When a new hospital is built or a surgical 
wing added, lucky is the city which has a donor of suffi¬ 
ciently open mind to present the operating-room suite 
and introduce into it all the desirable features known to 
date. An instance of this occurred very recently in 
Portland, Oregon, which, thanks to a private philan¬ 
thropist and a surgeon advising him, possesses, in the 
Clark Memorial Surgery of the Good Samaritan Hospital, 
all the equipment necessary to facilitate the work carried 
on there. It is impossible to graft an ideal system of 
heating and ventilating on an old plant. A hospital is a 
growth, usually beginning with a few beds, in an old 
private house, or with an afternoon clinic in a slum. Only 
in the western cities, which themselves are young, does a 
fully equipped many-sided hospital spring suddenly into 
perfect existence overnight as Eve did from Adam’s side. 
The construction of the operating-room suite is most 
costly and difficult, requiring innumerable sketches, sug¬ 
gestions and estimates, with visits to other institutions 
and careful listing of features required by those who will 
work there (Fig. 14). A council on building should con¬ 
tain representatives of all the elements interested: 

(1) Board of Governors. 

(2) Medical Board, 

(3) Architect, 

(4) Superintendent of nurses and operating-room 

supervisor. 

It is not to be forgotten that the last have just claims 
to be consulted. It has been proved that women have a 
flair for planning. Just as home planning has recently been 
perfected by the feminine influence, so has hospital plan¬ 
ning. Lack of space to work in, and the absurd ratio 
111 


112 


THE OPERATING ROOM 



Fig. 14.—Model operating-room suite. 


between number of beds and equipment were faults in the 
old buildings which impeded nurses’ work. Let the 
Board settle the limit of the cost, and devise means to 

















































THE MAIN OPERATING ROOM 


113 


obtain the money. The surgeons may speak of the por¬ 
tion affecting them directly, air-space, ventilation, tables, 
etc. The nurses should certainly have and express ideas 
relating to work-tables, closets for supplies, dressing- 
rooms, and business office. A safe proportion of their 
separate influences on the result can be struck by esti¬ 
mating the number of hours each will spend there. Nurses 
usually visit for comparison more than officials or even 
surgeons do. All drawings of the structure should be 
framed for easy reference in repairs. 

Position.—The suite should be very accessible, and yet 
cut off from the rest of the institution. This sounds 
paradoxic. In a skyscraper it should be at the top, 
with special elevator signals (particularly for fire-drills); 
on the cottage plan, it may be in a separate pavilion, 
centrally located. The heavy smell of ether should not 
reach the ward visitors. The noise of visitors, laundry 
or garbage collections should not reach the surgeons. 
In a pure atmosphere, one may demand clear thought, 
precise calculation, and quick, clean action. 

Size.—An operating room can be too large, wasting 
heat and energy in maintenance and cleaning. It can be 
too small, crowding the surgeon and menacing asepsis. 
The purpose of the room should be studied, the type of 
table, the paths to be trodden for supplies, all sketched 
out, then not one foot more or less constructed. It 
should be tested for its acoustic properties, to permit an 
operator to lecture in his clinics. 

Heating.—The most modern form of heating is com¬ 
bined with ventilation. Shafts in the walls lead to the 
engineering plant below, which forces drafts of air 
(washed and heated or cooled according to the season) 
into the room. These fan-driven currents find escape 
through vents in or near the floor, which discharge to the 
atmosphere, so that workers do not rebreathe their own 
carbon dioxid. This air must be obtained from a clean 
place and kept separate from the humid atmosphere of 
the sterilizing room. Steamed air depletes the vitality 
8 


114 


THE OPERATING ROOM 


of the nurses, ruins the instruments even in closed cases, 
and affects the texture of the walls. If hot-water heating 
is retained, it may be in one of two forms—(a) Coils 
flatly laid against the wall at a considerable height, not 
more than 10 feet, to permit easy cleaning; (6) coils on the 
floor, spaced at long enough distances to show and permit 
removal of dust, and covered after dusting with square 
boxed whitewashed covers to cut off the ascent of dust; 
(c) coils in alcoves in the wall with open grill in front. 
Heating from 75° to 80° F. is favored, since the patient is 
lightly dressed, his vitality lowered and his pores open. 
Special heed is taken to prepare him for transportation 
afterward. A recovery room, on the same floor, near bv, 
reduces chance of pneumonia. Trendelenburg requires 
extra wraps. Window deflectors send the heat upward 
from coils which must be set below the windows. Steam 
heating is not to be considered, because it is not uniform 
and leaves one unprepared for emergency work. 

Uniformity of heating means that the room shall be 
75° to 80° F. day or night, winter or summer, hot or cold 
days, with which fixed condition the dress of patients 
may always be the same. Nurses will require warmer 
clothing for the street when on this service than on others. 
Openings at the floor permit “gravity exhaust” of used 
air to shafts below. 

Finish.—Tiling is expensive in proportion to the perish¬ 
ability of all changing hospital construction. Plaster and 
paint are most common. The surface should not be highly 
glazed, on the contrary, a dull lusterless finish. Paint 
should be of a neutral color to clash as little as possible 
with the white of gowns or towels and the redness of a 
gaping wound, as the surgeon sometimes raises his eyes 
when palpating the deep tissues. French gray, dull 
greens, buff are among colors selected. 

Light.—There are two kinds of light: (A) Natural and 
(B) artificial. They cannot be employed simultaneously. 

(A) Natural light is not to be taken from any side but 
the north, as the absence of direct rays causes more equal 


THE MAIN OPERATING ROOM 


115 


diffusion. In an artist’s studio this is observable. A 
skylight is cold and uncleanly, as well as a menace from 
the elements. A glass projection, however, 2 feet deep 
and 6 to 8 feet long and reaching to the ceiling, serves to 
catch light from three sides, throwing it into all corners, 
yet casting no shadows. This requires storm sashes in 
winter. Windows may be, at least the lower half, of 
frosted or ground glass, for privacy, especially in large 
cities with other tall buildings. These windows had better 
be screened, in case the forced washed drafts from the 
engineering department fail, but if it is going well, the 
control of heat and ventilation is within and there is no 
need to open windows and expose the wound to city dust. 
Every window and door of a hospital should be screened 
and well guarded. If in the old style institutions win¬ 
dows must be opened for air, the curved box of finest wire 
netting, following the up and downward swing of one 
leaded glass pane, prevents a draft on the patient. A 
pane opening like a door is dangerous. 

(B) Artificial light should regularly be of only one kind 
in the presence of ether— i. e., electric—though provision 
is made with storage batteries for sudden interruption of 
current in accidents. It may be direct or indirect. Direct 
lighting is so arranged that bulbs hang directly over the 
table. These bulbs should be of frosted glass, to prevent 
shadows, and high enough not to burn the tallest sur¬ 
geon’s head. A glass plate should be slung underneath the 
bulbs to prevent dropping of dust, clear under frosted bulbs, 
and ground under clear. Nitrogen gas in a frosted bulb 
gives a powerful light with economy in current. For an 
ordinary operating room, six 100-watt tungstens make an 
excellent night light. In some old buildings a reflector 
is used, placed high for wide diffusion, even by day, when 
the sun is withdrawn. In buildings of the expensive type, 
an arched or angled attic is built over the operating room, 
with a ground glass floor studded with bulbs. None but 
the electrician has access to it, the small bulbs forming 
through the glass a glowing sheet in the ceiling of the 


116 


THE OPERATING ROOM 


operating room equaling a sunlit sky. Few can afford 
the wonderful Zeiss light which is generated outside and 
projected upon a number of mirrors, whence it falls in 
six or more intensively illuminating pencils upon the 
wound. These pencils do not cast a shadow if a person 
intercepts them. There should be no high lights or deep 
shadows or reflections on the inner surface of spectacles. 
Before purchasing, various companies should demonstrate 
on the ground that they can eliminate heat, shadows, and 
glare. 

For eye work, frosted or ground glass bulbs must be 
provided. Gazing into the retina, near the bulb, the wires 
or filaments must not be visible to form an antagonistic 
picture in the oculist’s mind. Every sort of droplight 
customary in eye hospitals should be here: 

1. To be wound with sterile gauze for the operator. 

2. To be held by a nurse. 

3. To be perfectly flexible so as to move 1/16 inch if 
required. 

The engineer is a very important member of the operat¬ 
ing-room staff. The nurses really must be taught by 
demonstration the meaning or uses of the following: 


Current, direct or 

10. Fuse. 

alternating. 

11. Motor. 

Transformer. 

12. Dynamo. 

Rheostat. 

13. Cautery. 

Switch. 

14. Filament. 

Watt. 

15. Nitrogen bulb. 

Cystoscope, auriscope, 

16. Tungsten. 

laryngoscope, etc. 

17. Plug. 

Battery. 

18. Socket. 

Dry cells. 

19. Vacuum. 

Storage. 

20. Meter. 


Rules for Keeping Electric Equipment in Order: 

1. Do not handle any apparatus without having had a 
lesson on it. 

2. Turn off the current before screwing in or unscrewing 
bulbs—it blows out the fuse and all the lights on one line. 


THE MAIN OPERATING ROOM 


117 


3. Keep the plan drawn by the architect, framed in a 
conspicuous place, showing the line of lights controlled 
by each fuse. (Note: All plans of plumbing and gas should 
be shown also.) 

4. Put chain sockets on all high lights, so that short 
nurses may reach them. 

5. Supply several switches on the walls, to control 
all lights in small groups, and modulate the amount of 
lighting. 

6. When connecting up an electric instrument, test 
the current first, then turn it off while screwing the 
plug in. 

7. Numerous base plugs make floor lamps possible. 

8. Apparatus must be dusted. 

9. Cords must not be coiled tightly or turned sharply 
back—this breaks the delicate wires and causes a short 
circuit and burn. 

10. Patients under anesthesia are easily burned. Never 
leave a bulb on the body with the current on. 

11. Repairs on the lighting system should not affect 
major operations. 

Comers. —Coved or rounded corners are best for ceiling 
and floor, permitting easy cleaning (dusting or flushing). 
The orderly must be taught to mop away from walls, and 
to bend his knees and wipe the walls separately with a 
clean hand cloth. It is not right to let cleaners have their 
own way, else the ancient history of the room may be 
read in the strata on the walls. 

Disinfection. —Modern laxity notwithstanding, the room 
should be disinfected regularly and after any unusual case. 
Modern methods of cleaning after infection have not yet 
been proved right. The test is whether we would wish to 
have a hernia done in the hour following a Gase after which 
we thought it unnecessary to disinfect. What is due the 
staff is due all patients. 

(a) Live Steam .—In the Methodist Hospital in Brook¬ 
lyn, N. Y., a connection is made with the boiler-room, 
by which when the room is closed, live steam is turned on 


118 


THE OPERATING ROOM 


for one hour through special pipes adjusted outside the 
door. This is necessary for every “septic” room. 

(6) Fumigation. —Based on the sort of infection, usu¬ 
ally a germ belonging to the vegetable kingdom—hence 
formaldehyd. 

(а) Seal all windows but one, closed only, easy 

to open. 

(б) Seal all apertures so as to permit not even a 

smell to reach the rest of the hospital. 

(c) Adjust fumigator (pump) at keyhole, or 

(d) Build pyramid of bricks, basins of water, dry 

basin of candles, alcohol and match, or 

( e ) Protect floor from stain by overflow if potas¬ 

sium permanganate is used—old rubber 
* sheet. 

(/) KMn0 4 , 5iv to formalin Oj to every 1000 

cubic feet of air space. 

(g) Remove everything which can be boiled or 

steam-sterilized for use in the interim. 

(h) Consult with Committee of Surgeons, basing 

disinfection on laboratory findings, so as 

not to upset schedule on too meager au¬ 
thority. 

(i) Candles of certain size and potency are made 

for certain proportions of existence. 

The operating room, in its broadest sense, should always 
be ready for use. A case may elude the most watchful, 
and show tuberculosis, typhoid, or some of the exanthe¬ 
mata. For the public feeling of security, no chances are 
ever to be taken. Hence a second room should always be 
available, possessing all the necessary characteristics, and 
equipment should be of a mobile nature—nothing nailed 
down. The late war has enabled many nurses to prepare 
themselves quickly for a complete “volte-face.” 

Doors should be plain, smooth, thick and heavy, to 
block sound, and swing both ways. The best of springs, 
set in brass boxes, flush with the floor, and handled as all 
expensive fittings should be, will enable a nurse to pass 


THE MAIN OPERATING ROOM 


119 


with a tray of instruments without losing her balance and 
possibly slipping on a wet spot with rubber heels and 
getting a wrench or sprain. Each door should be fitted 
with a small window of wired glass, about 1x2 feet, 
at the bottom of the upper third, flush with the wood, 
so as to enable one to distinguish the presence of a person 
on the other side. This prevents a head-on collision and 
the possible smashing of valuable instruments. Those 
scrubbed for operation remain in the amphitheater and 
must not pass through doors till finished. Doors should be 
made of wood thoroughly seasoned, so that they neither 
warp nor bind on account of the humidity. Doors are 
closed when a case begins. 

Perfect Cleanliness. —The eagle eye of the supervisor 
must detect any slips, “holidays,” or forgetfulness in the 
whole suite, carrying in her mind certain high points that 
are usually taken casually in a private house: 

Overhead lights, Tanks, 

Pipes, Coils, 

Projecting surfaces, Cords, 

Windows, Stools, 

Shades, Tables, 

Standards, Cabinet tops. 

Removing mere lumpy excrescences is not dusting in 
the true operating-room sense, but it consists of: 

1. Soap and water and brush. 

2. Sapolio on streaks. 

3. Labarraque’s solution on bichlorid stains. 

4. Sandpaper on roughnesses. 

5. Oxalic acid on rust. 

6. Whiting on paint, 

Silicon. 

The real potency of one’s religion is easily discovered 
in the ardor and thoroughness of operating-room cleaning. 
True honesty in nurses makes this room the Verdun of 
the germ. Had each nurse a gaping wound over her eye, 
she should not fear to have it swabbed with swabs from 
any corner of the room she cleaned. Next to cleanliness 


120 


THE OPERATING ROOM 


is order, which prevents confusion. Seeing germs from 
operating-room cultures grow in the laboratory may be 
an incentive to honesty. 

Plumbing.—A. Scrub-up stands: 

1. Must be visible and accessible at a wall with a long, 
open sweep, not in a corner where men jostle. 

2. How to turn on the water: 

(а) Knee-swell, fine in theory, but too delicate for 

practice—parts break. 

(б) Foot-tread, has worked out best. 

(c) Elbow—necessitates 2 faucets—not good. 

3. One faucet, containing mixture regulated below, 
usually preferred. 

4. Fixtures must be tested before each clinic, and re¬ 
pairs made in time. 

5. Members of other operating-units must not use 
this stand. 

6. Water must not return after one laving—hence no 
stoppers in bowls. 

7. Patented arrangement for liquid green soap to drop 
on hands by tip of elbow. 

8. Scalding by the sudden sticking of a hot-water fixture 
renders the surgeon hors de combat, makes him more 
susceptible to bichlorid, and benumbs the nerves used in 
palpating. 

9. Repairs in progress elsewhere in the building affecting 
the water-supply should be reported to the supervisor, 
and times chosen not interfering with necessary operations 
-—taps should be turned on and a large water-supply 
reserved—when the engineer turns on the supply, sedi¬ 
ment must not be allowed to run over linen or delicate 
instruments. 

B. Faucets from water-sterilizers: These are not im¬ 
paired as to sterility of the water by being carried through 
the wall. The presence of sterilizers in the main room is 
inimical to healthy tone. 

1. Must be controlled by foot-treads or keys. 


THE MAIN OPERATING ROOM 


121 


2. Should be polished by the orderly, then wiped with 
disinfectant by nurse when dusting. 

3. A portion is let off before using. 

4. Supply for hand-basins, irrigating tank, douche cans 
is obtained here. 

5. Regular testing and cleaning of filters is necessary 
(on the other side). 

Tables. —A. Operating: 

(1) Material—monel metal is preferred, easy to polish, 

every-wearing, impervious to solutions, non¬ 
chipping, showing no stains. 

(2) Structure: 

(а) Pedestal base most popular, with oil-pump 

and pedal to raise and lower to height re¬ 
quired by stature of surgeon. 

(б) Anesthetist should control, by one hand- 

wheel, which runs steel worm gears, noise¬ 
lessly. He needs often to decide and act 
very quickly. 

(c) Perineal recess made of nicalloy, a non- 

erosive, necessary for gynecologic surgery. 

(d) Etherizer’s screen aids asepsis, foot rests and 

knee crutches for Trendelenburg position, 
kidney elevator, etc. 

( e ) Goiter table permits head to be lowered. 

(/) For deep abdominal work, it is advantageous 
to tilt table to right or left. 

(i g ) Ball bearings necessary on all wheels. 

(3) x-Ray attachments: 

(а) For fracture work a special table is devised, 

the operator sitting on a stout saddle (for 
extension) and watching the approximation 
of the fragments by fluoroscope. 

(б) For cancer, fracture, ulcer, etc.-—shadow box 

on the wall, with plates previously made, 
showing up lesion, by transparencies. 

(4) Names of tables most used—Balfour, Hawley, 

Albee, and Ward. The table too heavy to move 


122 


THE OPERATING ROOM 


out to the anesthetic room may gain in solidity, 
take a good Trendelenburg, and be more easily 
wound up by the one hand of the anesthetist 
(Balfour). In committee the number of fixtures 
should be diminished rather than increased. 
Old-fashioned tables may be raised by sockets of 
lengths of gas pipe. 

B. Suture Tables .—Made of monel metal, and only one 
shelf (asepsis), also semicircular, preventing intrusion from 
outsiders. The rolling-stock of casters should be in dupli¬ 
cate for repairs. Lock rollers permit immobilizing. 

Stools.—These are necessary in graded heights, shapes, 
and lengths for surgeon (very stout), anesthetists, and 
circulating nurse if she has a minute to spare. The in¬ 
ternal feminine mechanism requires it. Psychologically 
speaking, the knowledge that one may sit helps to elim¬ 
inate fatigue. The surgeon stands an hour, working off 
his energy, then rides all day in his roadster. The nurse 
stands, waiting, and is on her feet all day. Long, low 
wooden stools at the table help for short persons and pro¬ 
vide resiliency. 

Clock.—A silent clock simply throwing out a sheet, 
announcing the hour and minute in big block letters is a 
good feature; the exact knowledge of the time remains in 
the mind better when read thus, “2.20,” than when cal¬ 
culated from a picture of two hands. 

Signals.—Electric signals may be arranged in the floor 
or at the base, to be operated by the foot, giving a silent 
call to the other portions of the suite for the circulating 
nurse. This system is operated by the suture nurse or 
supervisor, just as a hostess summons a maid. 

Blackboard.—Messages for operating surgeons may be 
written on a blackboard—records of sponge count also— 
calls for interns to their wards. 

Table Pads.—Stretchers and tables should be provided 
with stout pads of curled horsehair with air compart¬ 
ments, boxed at the edges to remain square and prevent 
the patient from rolling off the table. Their softness saves 


THE MAIN OPERATING ROOM 


123 


the patient’s tissues. They do not affect the position re¬ 
quired for the organs. Fatigue and bedsores are eliminated. 

Cautery. —The fixtures for the cautery should be in the 
main room, but out of the way of the operator. If ar¬ 



ranged on a low truck of heavy pine, built with cover and 
solid casters, they may be: 

(1) Easily moved forward when needed, 

(2) Kept clean and free from dust, 

(3) Easily disconnected and repaired. 



























124 


THE OPERATING ROOM 


Ejector.—Provision must be made for evacuating in a 
cleanly manner large cysts or other bodies containing 
serous or purulent exudates. If included in the original 
plan of the engineering department, the room may be 
equipped with a large aspirating set capable of drawing 
off several gallons of cystic fluid without letting a drop 
fall on the floor. The smallest size of “H. D. Ejector” 
(Fig. 15) does the work very efficiently. It is connected 
with the high-pressure steam of the boiler-room and dis¬ 
charges “to the atmosphere,” into a hopper, etc., by 
breaking pipe connection. 

To the suction opening of the ejector, in the wall of 
the operating room, is connected a rubber tube leading 
to a bottle partly filled with water or disinfectant liquid. 
From the patient’s body, at the point of aspiration, is 
another rubber tube, leading from the needle to the bottle. 
By opening the valve at the wall the fluid is forced to move 
off from the cavity by suction, passing into the bottle, 
where it remains, while any residual air of the system, 
which may be drawn in at the same time, passes on 
through the ejector and is discharged to the atmosphere. 
When the air is all expelled, the cystic fluid follows it “to 
the atmosphere,” i . e., drains. 

Waste Receptacles: 

I. Unclean, but used over or examined: 

(a) Empty dressing covers—light fiber basket. 

( b ) Gloves—basin. 

(c) Brushes—basin. 

( d ) . Instruments—basin. 

( e ) Tape sponges—pail. 

(/) Sheets and towels—hamper on casters. 

(g) Specimens—basin. 

II. Unclean, to be counted and destroyed, etc.: 

(a) Small sponges—pail and special forceps. 

(b) Hair from shave—separate basin, not mixed 

with sponges. 

( c ) Tissue—not for examination—basin. 

(d) General waste—pail. 


THE MAIN OPERATING ROOM 


125 


All waste receptacles should be of enamel or fiber, so 
as to be totally impervious to liquids if required, or to 
dampness. They must admit of scrubbing with soap and 
Sapolio and wiping with disinfectants. Hampers should 
be provided abundantly with white duck or canvas lining 
washed with each load and always bleached to a snowy 
whiteness. Pails requiring covers should be operated by 
the foot only. 

Scrub Pails. —When the floor is scoured, the pail of 
the cleaner should stand on a rubber mat, or have a 
rubber bottom, to prevent noise and scratches on the tile. 

Irrigating Tank. —The large tank for soaking should be 
covered and kept well oiled and dusted. 

Cabinets. —Steam or hot-water pipes conducted through 
tall narrow cabinets of metal, maintain the proper tem¬ 
perature for Florence flasks of saline which should always 
be ready for stimulation. These cabinets should be en¬ 
closed recesses in the walls, in which the pipes must run. 

Instrument Cabinets. —Though referred to here, these 
should not appear in the main operating room. For a 
large suite, they may be collected in a special room, in a 
dry well-lighted place. For a small system, they may 
stand outside the main room, locked, but of easy access. 
When an additional instrument is needed during an opera¬ 
tion, the shortest possible distance should be taken to 
get it, boil it and carry it on a tray to the suture 
nurse. 

Elevators. —Similarly, though the elevators do not de¬ 
bouch into the operating room, they must be near, so as 
to eliminate the effects of drafty corridors. The angles 
by which a stretcher travels from a fixed table, through 
the operating-room folding-doors to the door of and then 
into the elevator must be measured for and made prac¬ 
ticable. The elevator must freely admit a stretcher and 
the necessary passengers accompany it. For fire drill, 
the elevator should run to the operating room and remain 
there. The control of the elevator during operations should 
rest with the operating room, not with the first floor. 


126 


THE OPERATING ROOM 


The elevator shaft may contain signals for the arrival of 
operators, audible in the workrooms, or visible, if silent. 

Flooring. —The main room should have flooring which 
will possess lasting qualities, since repairs impede busi¬ 
ness and impair the usefulness of the institution. The 
texture should be such that it will withstand frequent 
washings, scourings, and disinfectants. It must be con¬ 
stantly mopped dry, so that a nurse, whose rubber heels 
quickly grow smooth, may not turn quickly on a moist 
spot, sustaining a fall or a bad wrench. For work other 
than regular operating it may be laid with corrugated 
rubber mats temporarily. An immense variety of materials 
is on the market, and the more resiliency can be com¬ 
bined with the above qualities, the better for the nurses. 
With proper care during time off, resting on a bed, the 
feet elevated at an angle of 45 degrees, with a minimum 
of time in the main room, and resilient flooring on the rest 
of the suite (cork, linoleum, corrugated rubber, wood) the 
suture nurse can round the corner of the last lap of this 
service without permanent harm. 

Summary. —The keynote of an operating room should 
be simplicity. This is the basis of honesty, cleanliness 
and industry. 


CHAPTER VII 

THE STERILIZING ROOM 

“Cleanliness is next to godliness.”— Old Adage. 

Definition of Sterilization. —It is the complete destruc¬ 
tion of all organic matter, whether pathogenic or not. 
Conscientiousness is the essence of this contract. To 
lessen by one minute the time prescribed for the thermal 
death-point of bacteria may spell death to some patient. 
Overtime is wasteful and indicative of inaccuracy. In 
the case of rubber goods overtiming spoils the material. 
The arena for the process of sterilizing must be con¬ 
sidered as a whole, and each part of the equipment or each 
method applicable to various types of material must be 
regarded only as one of many different means to the same 
end—the patient’s safety. 

Methods of Sterilization: 

Thermal: 

(а) Boiling—instruments, lying in water. 

(б) Steaming—utensils, confined in tank of live 

steam. 

(c) Steaming under pressure—dressings, rubber 
gloves, towels permeated but not wet by live 
steam. 

(i d ) Baking—in an oven—suitable for special appa¬ 
ratus, or in improvisation in private house. 

Chemical: 

(a) Solutions—alcohol, lysol, formalin, etc. 

(b) Gaseous—fumigation with formaldehyd is an 

aid, but does not sterilize. 

Sources of Heat. —For thermal sterilization the different 
heating agents are singly, in order of merit: 

Steam under pressure up to 35 pounds, 

Live steam unconfined (longer)*, 

127 


128 


THE OPERATING ROOM 


Electricity, 

Gas, 

Petroleum, 

Alcohol. 

It is a safe rule to boil all articles that can be boiled. 
There are combinations of these, e. g., gas and steam. 
Preparations Before Sterilizing: 

(а) Washing—all visible dirt must be washed off 

gloves, instruments, dressing covers, et al. 

(б) Filtering—water. 

(c) Chemical helps—washing soda (sodium carbon¬ 
ate) to increase the temperature. 

(i d ) Suitable covers—all dressing cases must be double 
stout muslin, clean, big and clearly marked, 
uniform in style, neatly and securely folded. 

( e ) Cleaning the sterilizers inside. 

(/) Cleanliness of persons operating sterilizers. 
Mechanical cleanliness must be achieved first. It is 
absurd to put on the sterilizers the burden of destroying 
all forms of dirt. The risks run by any sterilizing room 
are very great and wearing, for the following reasons: 

(a) The overlapping of duties of many individuals of 

varying degrees of reliability: 

(1) The supervisor’s eye cannot always be on the 

works. 

(2) Nurse pupils may have erroneous conceptions 

of the mechanism of the equipment. 

(3) The orderly, 

If he has brains, likely has no principles, and 
If he has principles, likely has no brains. 

(b) The goods to be sterilized are full of deadly menace 
—coming from pus cases steadily, in very short cycles 
from case to case. 

Protection of the Sterilizing Room: 

I. All germ-laden material should be cleansed as far as 
possible by mechanical and chemical agencies before 
carrying it into the sterilizing room, which is the keystone 
of the fragile arch of asepsis to be maintained throughout 


THE STERILIZING ROOM 


129 


the suite. In no sense is it a workroom. It must be placed 
in the plan, in the cleanest portion of the series of rooms. 
Dust must be excluded. Bundles must be handled with 
care, on trays, not next the person. Lubricants, liquids, 
powder, and other forms of “clean dirt” must not remain 
on goods destined for the sterilizer. 

Consider the routes traveled by each type of article, and 
the means one should take to reduce to a minimum 
the burden of the sterilizing room and the menace to the 
patient. 

Read going with the hand of the clock—the hours indi¬ 
cate places on these routes. 

Gloves laden with pus germs are drawn off in the operat¬ 
ing room at 12 o’clock, and are dropped into basins of dis- 



Fig. 16. 


infecting solution, preferably lysol, which will not conflict 
with soap afterward, rendering them innocuous to the 
nurse who washes them while “alive,” though she’should 
wear stout rubber gloves for “dirty” work. This is done 
in the hopper room at 3 o’clock, out of line of the operating 
or sterilizing rooms. Many hospitals have had inviting 
hoppers in the sterilizing rooms, to which, on account of 
the short distances, all dirt was carried. The hopper 
room serves as the assembling point for all dirt, to be 
removed, and to permit forwarding the articles to more 
powerful cleansing agents. A small set of boilers, and 
tanks or tubs of disinfectants in this room enable the 
nurse to send out everything in a condition harmless to 
others: 

9 


130 


THE OPERATING ROOM 


The next nurse, 

The laundry staff, 

The future patient. 

These persons must be considered, especially the laun¬ 
dresses, who are ignorant of the death-dealing germ, and 
are harassed to deliver a daily quota of finished work. If 
gloves have been boiled and hung on their trees to drain, 
they may then be moved to the workroom at 6 o’clock, 
to be sunned, aired, and turned. Vitality of germs is 
lowered by exposure to the sun and by absence of food. 
Here the gloves are powdered if required, and done up in 
sets of three pairs for the surgeon and his regular assist¬ 
ants. This is possible in institutions with stable methods. 
They are then packed in drums with dressings and sheets 
for his clinic day, to be wheeled later on a drum cradle 
into the sterilizing room at 9 o’clock, there sterilized, 
stored, and later wheeled into the main operating room 
at 12 o’clock, where a clean case should be perfectly safe 
with those same gloves that were smeared with pus the 
day before. Mending occurs in the workroom when 
required. 

Instruments are collected after a dirty case (pus, cancer, 
typhoid, exanthemata, etc.) at 12 o’clock, in a basin of 
lysol, carried to the hopper room at 3 o’clock, carefully 
taken apart, by a gloved nurse, having excrescences 
brushed off (grease, blood, tissue, threads), then boiled 
and lifted out on a tray into a large basin of green' soap 
solution. They may then safely be carried to the work¬ 
room at 6 o’clock, polished with Bon Ami and alcohol, 
dried, warmed and oiled at the joints, then laid on the 
shelves at 8 o’clock, where they rest in their circuit for a 
while. When needed, they go to the sterilizing room at 
9 o’clock, at the last quarter hour of preparation for the 
clinic also, are boiled and carried on the tray to the suture 
nurse at 12 o’clock, having no impurity on them. 

Towels are collected in sanitary hampers at 12 o’clock, 
and wheeled to the hopper room at 3 o’clock, where they 
are put to soak in cold water plus a disinfectant, when 


THE STERILIZING ROOM 


131 


necessary, that will not stain. They stand for a pre¬ 
scribed period, then are brushed with a long-handled 
brush by a gloved nurse, rubbed if necessary by hand, and 
thoroughly examined for: 

(1) Stains, 

(2) Clots, 

(3) Tissue, or specimens of value, 

(4) Instruments, 

(5) Pillows, 

(6) Rubber sheets 

which have often been carried down, and cause trouble, 
because 

(1) It is wasteful and careless, 

(2) It impedes the laundresses, 

(3) It reduces the equipment of the operating room, 

(4) It breaks or clogs the laundry machines. 

(a) Towels from a pus case may then be boiled in a 
small stationary clothes boiler on its own burner, in the 
hopper-room, if they are few in number, in ratio to the 
total number of cases handled, then sent to the laundry 
at 5 o’clock. Every step taken to shorten the journey of 
infected material pays. 

(b) Otherwise—they may be tied up in a special sheet, 
marked “infected,” and sent down by the. freight elevator 
to the laundry and boiled at once. They should not be 
run through the chute, through which “clean” goods must 
go. By visiting the laundry (without casting any asper¬ 
sions) a nurse may see the degree of heat used in the 
machines, and satisfy herself about the amount of dis¬ 
infecting the laundry does. A large number of workers of 
the shrewd, maybe, but uninformed class are interested 
at 5 o’clock, without self-protection against germs, and, 
on account of living indoors, usually in darkness, moisture 
and heat, those three friends of the germ, without im¬ 
munity. Hence the nurses, who know better, should 
never forward linen that is not disinfected, particularly, 
too, because the ward linens going out thence are not 
sterilized. 


132 


THE OPERATING ROOM 


At 6 o’clock the towels arrive, are straightened, folded, 
then divided thus: 

(1) Wrapped for immediate sterilization at 9 o’clock: 

(а) To be used on next day’s case at 12 o’clock, 

(б) To be laid away in sterile reserve. 

(2) Wrapped for reserve in readiness to sterilize in 

store-room. 

(3) Loose: 

For anesthetic room, 

For reserve. 

By concentration on these far from vicious circles, and 
by zealous watchfulness at the sterilizing-room door over 
all incoming goods, it is quite possible to prevent or stamp 
out infection. Needless to say, after using so much 

(1) Labor, 

(2) Heat, 

(3) Time, 

(4) Skill, 

in sterilizing a package of towels, the nurse who handles 
it afterward must be four times as careful as she might 
casually think, in order not to drop them or defile them. 

II. Goods from a house of contagion or venereal dis¬ 
ease should not be brought to the sterilizing-room (e . g., 
an obstetric bundle). 

III. The personnel of those who make dressings should 
be certified to be clean from tuberculosis or other diseases. 
These persons may be: 

(a) Red Cross home nurses, 

( b ) Hospital junior auxiliaries, 

(c) Probationers. 

IV. Goods to be sterilized must be placed in tubes or 
covers of special design: 

(a) Glass tubes for packing are made specially 

with two ends open, so that the steam may 
thoroughly permeate the entire contents. 

(b) Covers of muslin are double. 

(c) Glass jars or flasks should be open, lids in¬ 

verted, smooth surfaces and rounded corners. 


THE STERILIZING ROOM 


133 


V. The personnel of this room must protect themselves 
from each other. How to pack a drum is a vital point: 

(1) A lining sheet or bag; (2) what is needed last is put in 
first, and vice versa; (3) name of the packer on a printed 
slip, under lid; (4) date of sterilization on tag outside. 

Direct reprimands are the only safeguard for a nurse’s 
future. 

Drums must be scoured inside—rust or other chemical 
compounds must be eliminated, which would act like a 
foreign body, irritating a wound. 

VI. Street dirt must be kept out—floating bacteria 
should be eliminated, so that packages just withdrawn 
from the chambers of the autoclaves will not be con¬ 
taminated. 

(1) Galoshes or sneakers for operators. 

(2) Heads shampooed—caps at work. 

(3) Hands scrubbed, nails trimmed close, run ends 

of fingers in hard soap before doing dirty 
work requiring bare hands. 

(4) Stretchers cleaned frequently. 

(5) Ward supplies done in ward sterilizers if pos¬ 

sible—if not, at a special time, without con¬ 
tact of operating room. 

(6) Articles on which patients breathe must be 

boiled, washed, or sterilized by steam, as the 
case may be. 

(7) Visitors must be covered. 

The sterilizing room nurse should be more anxious, if 
possible, than any other person, about the clean result of 
a hernia. 

VII. The room must be entirely cleaned regularly. 

VIII. When an infection has occurred, a council should 
be held, and all the participants in the tragedy questioned 
and given a fair hearing. 

IX. Nurses with tonsillitis, influenza, or infected fingers 
must be taken off duty. The pupil should be well fed, and 
given opportunity for exercise, then time deducted for 
loss of duty. They should dress suitably for the seasons 


134 


THE OPERATING ROOM 


and keep good hours, conserving their strength and re¬ 
sistance to infections at this critical time. 

X. Buy good catgut—do not try to make it—best is 
from intestines of range sheep, not subject to anthrax— 
home-made leaves room to blame pupils. 

XI. Holes must be mended in gloves and towels. A 
slit glove should be immediately exchanged for a good 
one. 

XII. If wards are supplied with dressings, there should 
be a careful system of bookkeeping to show the reason for 
and the extent of all requisitions, with the return of empty 
covers. Legitimate expansion must be met. Drainage 
cases may use a cheaper grade of gauze or cotton. 

Principles in Architects Plan: 

1. This room must be near the operator, on account of 

(a) Hot water, 

(b) Hot blankets and water bags, 

(c) Reboiling instruments. 

2. It must be out of the line of travel of dirty goods— 
not a catch-all for pus. 

3. It should be on the top floor: 

(a) . To provide vent for steam, to the outside, 

visible through glass. 

(b) To get .the aid of sunshine and breeze, 

(c) To prevent its noises from waking or frighten¬ 

ing patients. 

4. A skylight is beneficial, which permits easy opening, 
one pane, or the whole. 

5. It must have an EXHAUST FAN to evacuate 
heat and humidity, and remove this cause of depleting the 
nurses’ vitality. 

6. All fittings must be easily controlled, modern, easily 
repaired, cleaned, tested, and polished. 

(а) Valves in front of autoclaves, 

(б) Switches on free wall space, 

(c) Cut-offs for 

Gas, 

Steam, 


THE STERILIZING ROOM 


135 


Electricity, 

Outside and inside the room (room might 
be unsafe to enter, due to fire, storm, 
etc.). 

(d) Pedals for big utensil tanks. 

7. Every means to burn, scorch or scald a nurse, and 
any heavy lifting must be eliminated. Servants should be 
insured under the Workmen’s Compensation Law. Nurses 
never are. 

8. It must be accessible to the night staff so that they 
may, when necessary, have the water for the day boiled 
and cooled for early cases. 

9. AN OPEN AIR SHAFT to a loggia below and 
to the sky above will provide a vent for the humidity 
which usually saturates the atmosphere of the main room. 
If there is another story above, a loggia may be planned 
there, to create the free passage of air. Two stout swing 
doors on the shaft, and a light vestibule in the operating 
room keep the cold out. The shaft is so narrow that a 
nurse is not chilled, yet it is wide enough to condense all 
moisture. This keeps up the energy, presence of mind, 
and endurance of the nurses when engaged in the most 
important service—at sutures. It reduces the surgeon’s 
perspiration and also the opening of the helpless patient’s 
pores. Humidity robs nurses of their color—they usually 
look as if they lived in a Turkish bath-house. They are 
susceptible to diseases of the respiratory tract, for which 
they stay off duty, reducing their strength and causing 
the institution expense. Chipping of paint and falling 
of plaster are checked if humidity is minimized. If the 
shaft is bounded by the sky, a small roof will prevent rain 
or snowfall. The gangway between the two rooms re¬ 
quires high balustrades. 

10. Flooring should be resilient, to minimize fatigue and 
headache. It should not be too smooth, for, when wet, 
it causes sprains and strains, if a nurse turns in a hurry 
when her rubber heels are slightly worn. Corrugated 
matting is good if cleaned well. 


136 


THE OPERATING ROOM 


11. Capacity of equipment (water, dressings, etc.) is 
based on (a) the number of surgical and obstetric beds; 
(6) the relation of wards, accident room, clinic, to this 
service; (c) the possibility of expansion without instilla¬ 
tion of this type of equipment in the new sections; ( d ) 
the probability of emergencies, epidemics, railway or 
factory accidents. If the hospital is carrying its peak 
load in ward beds, all services connected therewith should 
be capable of uniform expansion. 

12. The sterilizing room should be open to the path¬ 
ologist for the severest tests at any time. 

Equipment: 

A. Water Sterilizers: 

1. Blessed be they who give the wards their own 

sterilizers—main capacity ranging from 6 to 
100 gallons—large enough to meet the de¬ 
mands of the institution when carrying its 
peak load. 

2. Set on a solid pedestal, quite high, and out far 

from the wall, to permit easy handling and 
cleaning. 

3. Two faucets on each, one carried through the 

wall to the operating room. 

4. Both should contain a cold coil. No matter how 

much water has been used, the balance in 
both can be more quickly heated than 
filled, boiled, and cooled down. The cold coil 
is of copper coated with pure tin. 

5. Must be run every day—water is not sterile 

after twenty-four hours. It is a good plan 
to boil early. 

6. In small town hospitals which begin with gas, 

the parts for steam fittings should be in¬ 
stalled at the beginning also. 

7. Vessels brought to the sterilizers must be 

sterile, covered with a sterile towel. 

8. Must be of pure tin inside. 


THE STERILIZING ROOM 


137 


9. Some firms make water drums with a folding 
spout, and holding 3 gallons, brought in on 
drum cradle like dressing drums. 

10. To prevent the noise of the blowing off of the 
steam safety valve, when all conversation is 
suspended, there is made an automatic 
steam control valve connected to the steam 
supply pipe (ditto, if gas). 



Fig. 17.—Sterilizing-room detector. 

11. Every Sterilizer Should Be Fitted With a 
Sterilizer Detector, designed to keep tab on 
the consciences of the nurses. (See Fig. 17.) 
A pen, moved by the varying pressure of the 
steam, records, in a red ink line, the con¬ 
stancy (or lack of it) of the pressure in the 
sterilizing chamber where the dressings are, 
on a dial set at the front of the autoclave, 
or water boiler. It is encased in glass, and 
has a lock, of which the supervisor only 




138 


THE OPERATING ROOM 


should carry the key. The removable 
papers show the records for twelve hours. 
Water must be boiled at 15 pounds to the 
square inch or 250° F. 

12. Every steam apparatus must have gages. 

13. Sterilizers must be constructed with great 

strength—the average young girl who op¬ 
erates them has no true conception of the 
force of steam. The danger from ignorance 
is equal to that of the germ. 

14. Dangers of water sterilizers: 

(a) Bursting—must be thick, with sound 

seams, and allow for expansion. 

(b) Blowing off—steam safety valves must 

be tested. 

(c) Leaks—draw off cocks are necessary. 

(d) Refertilization—air-filtering valves are 

required, together with daily boiling. 

15. May be boiled up by the night force for early 

morning work. 

B. Filters: There should be two stone filtering bougies, 
one being scrubbed, cleaned, and aired while the other is in 
use. 

C. Hot Towel Sterilizer: Luxurious fittings, saving the 
nurse’s time—in two compartments, towels above, heated 
water below, keeping towels hot and moist (tapes for 
shock, intestinal work, etc.). 

D. Utensil Sterilizer: 

(1) Should stand very low. 

(2) Opened by a hydraulic lift. 

(3) No strain in lumbar region when lifting out. 

(4) Boil early, to cool, and not scald the arms. 

(5) Pair of clamps to lift out basins, which should 

be put in face down, to permit lifting by 
hand if necessary. 

E. Instrument Sterilizer: 

(1) Usually stands too high, and steams the face. 

(2) Pair of clamps to lift out instrument tray. 


THE STERILIZING ROOM 


139 


(3) Add 1 or 2 per cent, borax or sodium car¬ 

bonate to prevent oxidation on the instru¬ 
ments, to raise the temperature of the water 
and check discoloration. 

(4) Should open with hydraulic lift. 

(5) Electrically heated should have automatic 

cut-off. 

(6) Thin layers of muslin between instruments 

help in sorting kinds. 

F. Dressing Sterilizers: 

(1) Preferably the autoclave with drums. 

(2) Small cylinders, 10 inches in diameter, and 20 

inches long (or longer) are preferred by 
nurses, who, owing to the ubiquity of most 
orderlies, must handle the drums. 

(3) Autoclave and drums are of copper and 

nickel plated. 

(4) Stand made of four legs on a frame shaped like 

a half barrel, a rolling cradle, acts as carrier 
for drums, to load into sterilizing chamber 
or push to operating room. 

(5) Low truck helps if rolling cradle is not pro¬ 

vided. 

(6) Door of chamber must be provided with a 

ring of packing to close against—coated 
once a week with graphite to keep pliable. 

(7) Best for all if wards can have their own 

sterilizers, where wounds cannot (easily) be 
infected. 

(8) Damp dressings are not sterile. If withdrawn 

damp, they immediately can be contam¬ 
inated by their surroundings, the hand that 
holds them, the shelf on which they are 
laid. They should be opened, dried com¬ 
pletely, wrapped, and sterilized. (Note, not 
again , because they were not at all.) If a 
nurse finds them damp, she should bravely 
confess her fault and do them over. There 


140 


THE OPERATING ROOM 


should be a reserve of sufficient bulk to per¬ 
mit the thorough correction of this mechan¬ 
ical error or carelessness. 

(9) Construction of dressing sterilizers: 

I. The autoclave consists of: 

(а) A long cylinder (into which the dressings go). 

(б) An insulator wrapping it (but invisible). 

(c) An air space outside of this, of larger diameter, 

called the jacket. 

(d) A long metal cylinder outside all—like one 

small baking-powder tin inside another, and 
the lid of the larger clamped on. 

II. The pressure steam from the boiler-room is turned 
on into the outer chamber or jacket for a few minutes, 
and when the gage reads 15 pounds for the jacket, it is 
time to draw off the air that was in the chamber around 
and among the bundles of gauze, therefore the vacuum 
valve is opened. When there is a complete vacuum in the 
inner chamber (of dressings) it is shown on the gage. 
Close the vacuum valve. Turn the steam into the dress¬ 
ing chamber, at high pressure (17 pounds) for twenty 
minutes or more after the air stops escaping from the front 
pet cock and the steam shows. The steam must be with¬ 
drawn before there is contact with air, or condensation 
will occur, hence the vacuum valve is opened, and the 
steam drawn off. This registers “vacuum” on the gage. 
Then the steam is turned into the jacket, to dry the 
dressings, at low pressure. 

III. The valve dial at the front is marked “vacuum,” 
“steam into jacket,” and “steam into chamber,” with one 
lever only to throw over on each—very simple. 

IV. The total formula is 

“Steam into jacket.” 

“Vacuum” (in chamber, air taken out). 

“Steam into chamber”—twenty plus minutes. 

“Vacuum in chamber”—(steam taken out). 

“Steam into jacket.” 

V. Glass tubes for packing should be open at both ends 


THE STERILIZING ROOM 


141 


to permit live steam to rush through the contents with 
force. 

VI. Pressure of steam should not be allowed to go above 
two atmospheres (30 pounds) as it becomes a gas and is not 
a sterilizing agent any longer. 

VII. Safety device is required to hold the door shut 
while the pressure steam is on. 

VIII. Theory of Sterilization of Dressings. 

The germ cell is of albumin, that can be broken up or 
changed by heat. When albumin is moist, it is destroyed 
by heat at a low degree. 

When it is dry, a high degree of heat is required to 
destroy it. 

Some germs do not bear spores—this type is easily 
destroyed by a low degree of heat. Some are spore-bearing 
and require a high degree of heat to be destroyed. To 
moisten the spore is to prepare it for death in a shorter 
time (i. 6 ., at a lower degree of heat). Steam is moist heat. 
At 250° F. (15 pounds’ pressure) the albumin of spores 
is coagulated, hence destroyed. Hence also our fractional 
sterilization—dressings are “put through” three times, in 
order to destroy every spore, i. e., to be sterilized. 

G. Glove Sterilizers: 

(1) Lined with a bag—air squeezed out of gloves, 

to submerge. 

(2) Gloves sorted—good, bad, indifferent. 

(3) Must not be laid on radiators or other metal. 

(4) Tree used, with prongs, on which to drain 

(Johns Hopkins style) (made by hospital 
carpenter). 

H. Distillation Outfit: Can be installed in a corner 
with two faucets—may become cloudy—application of 
heat dispels—not to be regarded as sterile. 

I. Blanket Warmer: To save expense of piping, to 
have near the patient at the most critical time, the 
blanket closet may stand in the sterilizing room, or, 
heated from it, open into the operating room. It is prefer¬ 
able to have no hot closets in the main room. 


142 


THE OPERATING ROOM 


J. Clock: Alarm set for time sterilizers are due— 
permits nurse to go to other rooms if necessary—must be 
watched, and note made on pad in pocket of time goods 
are entered and to be withdrawn. 

Points to Avoid: 

1. Burns and scalds to nurses (helpers insured in 
Workmen’s Compensation). 

2. Strain and awkwardness in lifting. 

3. Explosions, floods, fire from short circuits cr frayed 
armatures. 

4. Dripping faucets, leaks. 

5. Wet dressings—quick medium for bacteria to 
thrive in. 

6. Mistakes in counting sponges in packing drums. 

7. Mistakes in operating the powerful forces of elec¬ 
tricity and steam. 

8. Running short of cold sterile water—all sterilizing 
should be completed (+ cooling + drying) before the 
hour set for a clinic to begin. 

9. Dirt on the inside of any sterilizer. 

Engineer’s Instructions: 

1. Pupils should be taught the laws of physics relating 
to water and heat (preferably in high school preparatory 
work). 

2. Construction and working of valves, water-jackets, 
coils, hydraulic lift, air chamber, air jacket, gage. 

3. Engineer makes diagram of the journej^ performed by 
the steam reaching into each sterilizer, tracing it on the 
real pipes. 

4. Steam under pressure is hotter—demonstrate this 
by adapted apparatus. 

5. Opening of valve at the wrong step may wreck the 
whole process and (as dressings are not sterilized) menace 
the life of the patients. 

Supervisor’s Duties: 

1. Demonstrate operation of all mechanism, and watch 
the pupil operate all of it till successful. 

2. Teach the value and necessity of conscience and 


THE STERILIZING ROOM 


143 


watchfulness. Diploma implies honesty and intelligence 
and preparation for pupil as future supervisor. 

3. No goods should be tied up for long (out of active 
circulation). One type of case, carefully studied, should 
have a standardized amount of goods packed, and no more. 
There should be a large reserve of sterile goods in double 
muslin covers, upon which to draw. To concentrate in 
the drum all that can be justly expected to be needed, 
and then to supplement with the reserve, everything ever 
known to be used if necessary, is good management. 

4. Inculcate every day the principles of clean work on 
typical cases like hernia. 

5. Send nurses to the wards to follow up what should 
be and is clean, or the disasters from an infection. 

6. Swoop down on the sterilizing room at times when 
the chambers should be evacuated, etc., and note if the 
pupil is taking steps to do so. Be conscious, even if not 
in the very room, of the timing of all processes. 

Printed Codes. —Here again the need is shown for 
standardization of all details behind the scenes. The 
differences observed in formulae, time, periods, pounds’ 
pressure, et at ., bewilder a nurse who visits two or more 
operating rooms. All directions for manipulating levers, 
timing boiling, etc., must be encased in glass, framed, 
printed in bold type, and hung in a conspicuous place, so 
that “she who runs may read.” 

(а) Tables for the number of minutes, the temperature, 
or number of pounds of steam for rubber, gauze, iodo¬ 
form, saline, etc. 

(б) Dates for inspection, overhauling, exchange, with 
address of manufacturers. 

(c) ' Directions for action in emergencies—flooding, 
leaks, fire. 

(d) Management of apparatus daily—less complex, 
more safety. 

(e) Materials for cleaning, emptying, filtering, polishing. 

(/) Guarantee by the company for repairs for a term of 

years (should always be obtained with purchase). 


144 


THE OPERATING ROOM 


General Notes: 

1. All eye pads, masks, or other special manufactured 
articles which have contact with the nasal or oral dis¬ 
charges of a patient or of the operating-room personnel 
must be sterilized. 

2. Petri dishes set exposed to the operating-room air 
show many pus-producing organisms (in one instance 131 
to the square inch). 

3. Nurse about to handle dirty material should draw 
her finger-nails across a bar of soap first to fill the space 
beneath the nails. 

4. The sterilizing nurse should protect her branch of 
the service by being clean and watching others. 

5. Washing heads, examination of throats and nasal 
passages, frequent taking of cultures from all hands just 
before putting gloves on, strict quarantine of dirty cases 
on the wards so that nothing from them can find its way 
back to the operating room, examination of new catgut, 
cultures from all infected wounds, rigid rules of behavior, 
will lead to prevention, discovery, or eradication. 

6. It is a disgrace for a hernia to be infected—the 
typical clean case. The pathologist, surgeon, and steril¬ 
izing nurse work together to discover the cause. 

7. It is a catastrophe to have a series of infections— 
there seems no excuse for it. The route for gloves, gowns, 
basins, etc., should be retraced. All materials used in one 
case should be sterilized and locked up. 

8. Always two persons on duty in the building some¬ 
where who understand the running of apparatus. 

9. Tap-water is safe in bichlorid tanks, minimizing 
demand on sterilizers. 

Details of Sterilization of Special Materials: 

1. Salt—measure, boil, filter three times through filter- 
paper and cotton—cleanse Florence flasks with green 
soap and alcohol, fill, plug, boil thirty minutes—then set 
in dressing-sterilizer for one period. 

2. Silk and silkworm-gut—boil empty jars ten minutes, 
or put through dressing sterilizer for ten to fifteen minutes 


THE STERILIZING ROOM 


145 


at 10 pounds. Boil silk or gut ten minutes, and put in 
sterile jars with sterile forceps, covering with alcohol 
70 per cent.—lids are always upside down in a sterilizer. 

3. Suture forceps jar—boil cork and jar ten minutes— 
fill with alcohol 70 per cent.—only inside kept sterile. 

4. Subcutaneous needles—put up with dry goods. 

5. Solutions: 

Adrenalin, boil one minute—pour into sterile 
bottle. 

Novocain—boil five minutes. 

Methylene-blue—boil in flasks ten minutes. 

6. Safety-pins and toothpicks—in uncovered jars— 
sterilize with dry goods—cover before removing from 
autoclave. 

7. Catheters—boil ten minutes, put in sterile towel 
with sterile forceps. 

8. Culture tubes—with dry goods. 

9. Dry goods—in autoclave 15 pounds (250° F.)— 
forty-five minutes. 

10. Fractional sterilization for what goes into abdomen 
or brain—sponges, rolls, etc. 

Time in 

Pounds. Degrees, minutes. Rest. 

First day 15 225 45 Twelve hours for 

spore formation. 

Second day 15 250 30 Twelve hours. 

Third day—similar, ordered by some surgeons. 

11. Glassware—boil jar containing, and glass goods 
twenty minutes. Fill jar with 4 per cent, boric acid or 
2 per cent, formalin—sterile forceps. 

12. Gloves—autoclave—10 pounds—225° F.—fifteen 
minutes. 

13. Rubber tubing—boil ten minutes—put in sterile 
jars in 2 per cent, formalin. Uncovered jars may be 
sterilized with tubing in them, in autoclave for fifteen 
minutes at 10 pounds, then filled with 2 per cent, formalin. 

14. Basins are boiled: 

Twenty minutes for major operations. 

Ten minutes for minor operations, 

to 


146 


THE OPERATING ROOM 


15. Handbrushes are boiled ten minutes. 

16. Filtered water (passed through cotton and filter- 
paper in a funnel) is boiled thirty minutes in its con¬ 
tainers which are previously cleansed with green soap and 
alcohol. 

17. Orange sticks (for the nails) are boiled ten minutes. 

18. Rubber tubing—another method—soak in chlorin¬ 
ated soda 1 :10 for two hours. Wash with soap and 
water, rinse, boil fifteen minutes. Keep in sterile boric 
acid or 2 per cent, formalin. 

19. Bougies, wash with cold water, and hang in a 
fumigation cabinet (formaldehyd). 

20. For suture table sterilize powder. 

21. It is claimed that good knives are tempered at 
500° F. and cannot be injured by boiling at 212° F. 
Rough handling or binding in absorbent cotton injures the 
edge more than high temperatures. 

Looking at the Sterilizing Room from Outside In: 

A. It is no use for one branch of the service to make a 
concentrated, prolonged effort to destroy bacteria in the 
small number of hospital patients in a large, careless 
community which disregards personal hygiene, house¬ 
cleaning and fumigation, or incineration, after contagion. 
Municipal Boards of Health should provide fumigating 
sheds, mattress sterilizers and crematories for infected 
carriages, mattresses, books, or garments. Public aggre¬ 
gations of infected material must not be brought on the 
hospital premises. 

B. Any business man will say that it is foolish for a 
hospital to equip a catgut-making plant and man it with 
pupils who have not enough time to do the nursing the 
patients require, and will never make catgut afterward. 
It is EXPLOITATION. 

THE DRESSING STERILIZER. ITS EFFECTIVE AND 
INEFFECTIVE USE 

Doctor LeRoy Broun, late Senior Attending Surgeon 
of the Woman’s Hospital, New York City, where, at one 


THE STERILIZING ROOM 


* 147 


time, the author was directress of nurses, has at my 
request given me the results of his study of steam steril¬ 
ization in hospitals. Dr. Broun says: 

My attention was first directed to this subject about 
1905, when an automatic contact bell, attached to one of 
the accepted types of sterilizers, failed to function; every 
effort to make it “go off” under the directions for using 
this dressing sterilizer failed completely. 

The essential for the proper functioning of the alarm- 
bell was that the circuit should be completed by the con¬ 
tact (through the expansion) of two metal surfaces. This 
contact occurred at the boiling-point of water, 100° C. 
This appliance was placed near the bottom of the steriliz¬ 
ing chamber, and the bell was attached to the outer shell 
of the sterilizer—a most excellent idea, to keep the nurse 
informed on the continued 100° C. temperature in the 
sterilizing chamber. On the self-evident value of this 
information several of these sterilizers had just been sold 
to a large hospital in Russia. 

An investigation by self-registering thermometers as to 
the cause of this failure showed that the lower part of the 
sterilizing chamber, where the contact appliance was lo¬ 
cated, did not reach the temperature needed for contact 
by the metal expansion, even after maintaining 15 pounds’ 
pressure in the chamber for thirty minutes or more. 

A further line of experiments showed that, though 
the temperature at the top of the sterilizing chamber 
quickly reached that of steam or boiling water, the 
thermometers placed midway and at the bottom of the 
chamber failed to reach this mark even after thirty min¬ 
utes’ exposure, the thermometer at the bottom registering 
the lowest. 

The sterilizer upon which these experiments were con¬ 
ducted was one of the universal type, being fitted with a 
steam suction arrangement at the top, called an “ejector,” 
for the purpose of exhausting the heated air from the 
chamber before the live steam is admitted. The effect 
of this preliminary exhausting process is to obtain in the 


148 


THE OPERATING ROOM 


sterilizing chamber a partial vacuum of 10 to 15 inches at 
most, usually not more than 8 to 10 inches. 

Since 30 inches represents a complete vacuum at the sea 
level, it is evident that fully one-half to two-thirds of the 
residual heated air still remains in the sterilizing cham¬ 
ber and in the meshes of the dressings, etc., contained 
therein. 

As to the effectiveness of dry air as a means of de¬ 
stroying bacteria and their spores, many experiments have 
determined that superheated air will not destroy the 
spores of pathogenic germs in blankets even after a three- 
hour exposure at a temperature of 133° C., and that it 
requires four hours’ exposure at a temperature of 140° C. 
for the destruction of anthrax spores. 

On the other hand, it has been equally shown that 
boiling water and live steam quickly destroy all spores 
and bacteria, only four minutes being required to destroy 
anthrax and its spores, and a less time for other patho¬ 
genic organisms and their spores. 

With this knowledge before us, we readily see the 
importance of not only freeing our sterilizing chamber and 
the meshes of all the dressings (in process of sterilization) 
from air, but also, by accomplishing this, of getting the 
desired uniform temperature of 100° C. throughout the 
entire chamber—even to the center of our dressing 
packages and drums. 

The residual air in the meshes of dressings from in¬ 
effective removal will prevent these areas from reaching 
the desired temperature and also cause the sterilization 
of these areas to be unreliable, on account of the in¬ 
effectiveness of heated air except under prolonged expos¬ 
ure, as spoken of above. 

Dunham, in an excellent article on the physics of steam 
sterilization, clearly brings this out in an admirable line of 
experiments. 

For the purpose of driving all of the air out of the 
sterilizing chamber and its dressings a most effective and 
absolute method is that of utilizing the steam of the ster- 


THE STERILIZING ROOM 


149 


ilizer, and not depending on the “ejector,” which is shown 
to be most ineffective. 

In all sterilizers the steam should be delivered into the 
top of the sterilizing chamber by a tube having its opening 
at the distant (back) end of the chamber. Steam stream¬ 
ing through this opening will drive the air before it, even 
from the minutest meshes of all dressings and packages. 

A stop-cock should be placed in the lowest position of 
the door of the sterilizer, and should be left open. If a 
rubber tube is attached to this open cock with its free end 
placed under water, the bubbles of the expelled air mixed 
with steam, as it is driven out, will be easily noted. After 
all the air is expelled and only steam escapes, the water- 
hammer sound—caused by the condensation of the steam 
in the cold water—is heard on a smaller scale, but similar 
to that heard at times in steam pipes. When this point 
is reached the entire chamber—even the center of the 
heaviest drums and of the dressing packages—will all 
register the same temperature of 98° to 100° C. 

If the pressure is raised to 15 pounds or more, the 
temperature will be correspondingly higher. 

Since superheated steam confined takes on the qualities 
of dry air and loses its rapid effectiveness for the destruc¬ 
tion of bacteria and their spores, it is important that 
the cock in the door should be left partly open—during 
the sterilization—in order that the steam shall be stream¬ 
ing in character and not have the ineffectiveness of dry air. 

As a result of our experiments we have, found that all 
the air is expelled from the chamber by this process in 
eight to ten minutes in the ordinary sized sterilizers. On 
this basis, the rule of allowing the steam to escape freely 
through the door pet-cock for fifteen minutes before the timing 
of the sterilizer is noted, has been adopted. The pet-cock 
is now partly closed for the purpose of maintaining the 
15 pounds’ pressure or more—and the timing of the 
sterilization begins. 


CHAPTER VIII 


MINOR OPERATING ROOMS, WORKROOMS, 
AND ACCESSORIES 

Reasons for Minor Rooms. —The make-up of an entire 

operating suite is based on the nature of the surgery which 
is presented by the community. In residential suburbs are 
found much 

(а) Preventive surgery: 

Adenoids, 

Tonsils, 

Circumcisions, 

Submucous operations. 

(б) Plastic surgery: 

Hernias, 

Gynecologic repair. 

(c) Emergency surgery: 

Brain (auto accidents), 

Fractures. 

In purely industrial centers there will be 
Amputations, 

Genito-urinary operations, 

Gynecologic infections. 

A council of all persons concerned, studying the plan 
of the suite by “the light of past history and with a forward 
outlook to expansion, should make a strong bid for doing 
all work hitherto attempted in the homes or done in some 
metropolis, or deferred forever. Division into clean and 
septic, light or dark, large or small, must be arranged in 
council. Climate and topography cause certain tendencies 
leading to a full harvest for specialists in those forms of 
surgery. The hospital must study its parish, and its 
needs, and try to equip for them, within the bounds of 
reasonable outlay and consequent fees. 

150 


MINOR OPERATING ROOMS, WORKROOMS, ACCESSORIES 151 

Special Rooms for Single Types of Surgery: 

A. For all “scopic” work, or operating with aid of a 
headlight, requiring simple equipment, concentration of 
skill on one small or obscure area, few dressings and few 
assistants, a small room is best. This is justifiable also 
on the score that these patients are guests of the hospital 
for one day only, and are not emergencies, therefore do 
not hold up the main room more elaborately equipped for 
a wider scope. For example: 

Tonsil Room: 

Special rheostats, transformers, and other fixtures 
(surgeon), 

Frosted bulbs or ground glass, flexible droplights 
(nurse), 

Fumigating cabinets for non-boilable apparatus, 
Separate instrument cabinets, 

Facilities for obtaining ice (hemostatic), 

Special rubber sheets, stout restraining sheets, 
Large wide-mouthed buckets, 

Suction apparatus to evacuate blood in throat, 
Tonsil table—-raise to sitting posture—seat of cor¬ 
rugated rubber matting to prevent slipping. 

B. Of all the organs of special sense the one most val¬ 
uable, most delicately sensitive, most frequently infected, 
and in its loss causing most damage and personal regret is 
the eye. 

Eye Room (operation, not treatment): 

Special tables, 

Electric fixtures (for emergency night work), trans¬ 
formers, etc., for “scopes,” 

Magnet to draw out foreign bodies of steel or iron, 
Extreme cleanliness without many disinfectants, 
Cabinet of eye instruments—special method of 
sterilizing, 

Special dressings—eye pads, masks, shades, 

Local anesthesia usually, 

Natural light for day work—must be good and 
generous, 


152 


THE OPERATING ROOM 


Suitable methods for marking, reporting, and re¬ 
cording— no mistakes must be made (e . g., 

enucleating good eye). 

C. When a patient is septic or venereal, it is not fair 
to contaminate the main room where a clean case fol¬ 
lows. Puerperal sepsis is one of the most insidious foes of 
a hospital. The expense of equipping a septic room is 
justified by the sense of security felt by the authorities 
and communicated to patients. 

Complete equipment—nothing ever taken out of 
this room to be used elsewhere—nothing lent to 
it from clean room; must be given and remain. 

Boiling, disinfecting, thorough, after each case, so 
that it would really be safe for a clean case 
every day. 

Careful diagnosis on patients assigned there. 

Isolation of patient afterward for consistency. 

Separate nursing force. 

Separate exit. 

Capable of being sterilized by live steam. 

Workroom: 

1. The room in which clean dry work is done 

Dressings, 

Plaster bandages, 

Mending gloves 

should be large, light and airy, to preserve the nurses' 
health and increase their output. 

2. Each nurse (4) should have her place to work at, 
and each sort of work should be done in a fixed place, 
kept tidy by her in charge. 

3. Windows should be modern in design, to admit air 
without drafts, and abundant light—always screened. 

4. Flooring should be very resilient, of rubber, or 
cork, or battleship linoleum, to rest tired feet, and cause 
no noise; also easy to clean, on account of the enormous 
quantities of lint and fluff. 

5. The walls are lined with cupboards to contain raw 
goods opened for work—doors plainly labeled. 


MINOR OPERATING ROOMS, WORKROOMS, ACCESSORIES 153 

6. The head nurse needs a substantial, well-appointed 
desk, with locked drawers, for 

(а) Patients’ valuables discovered by the anes¬ 

thetic nurse, 

(б) Operating-room records, 

(c) Nurses’ record cards while on this service, 

(d) Personal effects. 

7. First class lighting fixtures are to be provided, espe¬ 
cially lights directed into cupboards, or in' closets, and a 
very good lamp for the head nurse’s desk. Use light 
generously at work, but not extravagantly (fines). 

8. A spindle on the desk holds all memoranda relating to 

(а) Interns’ messages regarding cases, 

(б) Supplies needed, 

(c) Repairs found needed by pupils, 

(d) Time-off for nurses, 

and this should be cleaned off (executed) daily. 

9. A long, low, heavy deal counter stands in a well 
lighted, convenient place, with its surface always scrubbed 
spotless, and a bar underneath on which to rest the feet. 
It should be marked off in the sizes of gauze required for 
certain dressings, such as used by the American Red 
Cross war workrooms. 

10. Gauze cutting should be done by machine (by an 
orderly or porter, if possible), similar to the type used in 
clothing factories. 

11. For seats place heavy solid kitchen chairs made 
with a comfortable slant, so that the knees may go under 
the counter. 

12. Footstools and stepladder must be provided to 
reach the top shelves of cupboards—all these should be 
shod with rubber. Small stools have a hole in the center 
to lift them by. 

13. Sewing-machine run by motor is very necessary for 
mending in limited amounts, left-hand end at a window. 
Thimbles, needles, and thread in a basket. 

14. Electric iron, and patent collapsible ironing-board 


154 


THE OPERATING ROOM 


permit pressing out clean dressing-covers or mended 
articles—not for nurse’s personal use. 

15. Miter box, bandage knives, bandage rollers in con¬ 
venient places, with baskets (in nests) to contain cut 
bandages. 

16. Large assortment of bags as containers, hung on 
hooks at table or wall. 

17. A set of tea things or a coffee percolator will prove 
a good investment. If the nurses avail themselves honor¬ 
ably, of this privilege, the benefit of the stimulant will 
show in a garrison finish to a long, hard day. There 
should be no odor of coffee when patients and visitors 
are about. 

18. Thick glass slab on the table to make medicated 
dressings will save cleaning the deal table (boroglycerite 
tampons or iodoform gauze). 

19. Stationery consists of: 

(а) Operating-room report slips, 

(б) Chart leaves (for surgeon), 

(c) Sets of labels, 

(d) Nurses’ signatures to drop into drums or in¬ 

fusion sets. 

20. Cutlery, including knives, scissors, kept free from 
rust, and sent regularly to be sharpened with the instru¬ 
ments. 

Hints on Management of Workroom: 

1. Do all one kind of work at one time. 

2. Keep everything in its place. 

3. Clean up thoroughly at night in such a manner that 
work may be instantly resumed in the morning. 

4. Avoid continuous conversation and permit no in¬ 
timacies to be formed. 

5. Allow no visitors (physicians, special nurses, or 
patients). 

6. Dust the workrooms with damp dusters to keep 
down fluff. 

7. Alternate sitting with standing work—when sitting 
keep the feet off the floor, on a bar. 


MINOR OPERATING ROOMS, WORKROOMS, ACCESSORIES 155 

8. Nurses should address each other as “Miss A,” 
“Miss B”—never by the Christian name or the surname 
without the prefix “Miss.” 

9. Keep one nurse on duty in such a place that she 
can easily 

(а) Answer the telephones, 

(б) Present a good appearance, 

(c) Answer visitors’ or passing surgeons’ in¬ 
quiries. 

10. There should never be fewer than two nurses on 
duty, especially if engrossing work is going on, such as 
washing out blood and clots, or timing the sterilizers. 

Hopper Room. —The hopper room should be equipped 
with first class plumbing fixtures, fool-proof against being 
stopped up with all the articles and materials carried to 
this room, which furnished food to the engineers for so 
many bitter complaints, in the past, when all the grounds 
had to be torn up sometimes, tracing the cause of over¬ 
flows, till they said “they took everything out of the 
drains but a nurse.” 

(a) Hoppers for washing utensils, with spray—nothing 
to go down but water. 

(b) Hoppers for cleaning clots or other dirt which must 
go down—good trap. 

(c) Tubs to rub linen on washboard, to remove fecal 
stains, etc., plugs at bottom. 

(i d ) Tubs to soak linen in disinfectant—stoppered. 

(e) Stand to clean blood or pus off instruments, with 
basin and drain. 

(/) Good washstands for nurses, so that they may feel 
clean when through with the dirty work of the hopper 
room. 

(i g ) Lockers for each worker, with tools, mops, dusters, 
brooms, brushes, pails, Sapolio, etc.,, always washed, 
boiled, and sunned before putting in, with 

(h) Special ventilation, drying and heating apparatus, 
so as to prevent the heavy dank odors of mops, linen, 
etc. 


156 


THE OPERATING ROOM 


( i ) Sanitary flooring that will absorb no odors and yet 
not cause sprains and falls, or remain wet. 

(j) Printed codes for disinfectants: (1) Tanks of linen; 
(2) utensils; (3) instruments; (4) gloves. 

(k) Laundry chute from hopper room. When wet 
wash is sent down, a loud bell in the laundry, wired from 
the hopper room, rings a warning to take it at once—not 
necessary for dry wash. Chute must be water-proof and 
hosed out frequently. 

(Z) Modern contrivances to hold brooms and mops on 
walls, and to wring mops; also wire doors only, on lockers, 
for ventilation. 

(m) Lockers should be movable and sunned—not 
built in. 

(n) Racks for drainage-tubes, with pan below, not to 
wet floor. 

(o) Light trucks or .hampers on wheels, lined with 
laundered bags, for soiled linen. 

Store Rooms. —Of these there are usually too few, and 
without design. Just as the kitchen is the most impor¬ 
tant part of a house, requiring the most ingenious plan¬ 
ning and equipment, so the workrooms (including the 
sterilizing room) are the most important to the nurses, 
therefore to the hospital. Whatever facilitates a nurse’s 
finding or caring for materials helps the hospital. 

In the storage rooms should be: 

1. Stepladders and stools of varying heights. 

2. Shelves in cupboards with (a) solid doors; (6) 
wire screen doors. 

3. Counter—to measure only what is required in work¬ 
room (saves hauling). 

4. Precautions against mice eating shellac on bougies, 
etc.—metal drawers being best safeguard. 

5. Good lighting fixtures—to enable finding small ob¬ 
jects quickly. 

6. Careful division into compartments that equal in 
number the types of goods handled. 


MINOR OPERATING ROOMS, WORKROOMS, ACCESSORIES 157 

7. Careful wrapping in flannel, cotton, tissue, etc., of 
expensive instruments. 

8. Regular inventory and checking off of invoices of 
goods. 

9. Perfect system of labeling. 

10. Regular inspection and housecleaning. 

11. Heavy goods include gas and oxygen tanks, uten¬ 
sils in reserve, parts of the operating-room equipment, etc. 

12. Gauze and cotton room hold 1000 yards of gauze +, 
or 50 pounds of each grade of cotton +, according to the 
number of surgical and obstetric beds. To order once a 
month is usually satisfactory. 

13. Sterile and unsterile reserve room should be seldom 
entered, but built with good ventilation and lighting. 

Dressing Rooms for Orderlies. —The orderly should not 
go through the house in his “duty” clothes. He needs a 
small dressing room with toilet, so as to prevent the pos¬ 
sibility of his visiting others. 

Nurses’ Dressing Rooms. —The strain of operating- 
room work is so great that nurses must sometimes go 
without proper rest. Hence, any comfort that can be 
given by proper quarters in which to clean up, put on 
gowns, freshen one’s appearance, in a secluded manner, 
will be “for the good of the service.” They should be 
warm, well lighted, and equipped with shower, mirrors, 
wash basins, modern toilets, coat hangers, clock, hooks, 
and chairs. 

Doctors’ Dressing Rooms. —Add ash trays and Yale 
locks. 


CHAPTER IX 


ASEPSIS 

“This is the cat that ate the rat that ate the malt that lay in the 
house that Jack built .”—Old Tale. 

Definition of Asepsis. —Asepsis is defined as the ab¬ 
sence of pathogenic micro-organisms. In a different 
word, it means freedom from disease-producing germs. 
This condition splits into two parts. It must be 

I. Created by boiling, steaming, fumigating, or dis¬ 
infecting with chemicals; then 

II. Maintained by clearly understood operating-room 
methods, relatively for one patient at a time —not abso¬ 
lutely for all time or for a whole clinic. 

Asepsis rests on the foundations of conscience and in¬ 
telligence. 

The creation of the condition has been treated under the 
head of Sterilization. But things do not remain in a 
sterile state. When one broils steak, it remains broiled 
and never becomes raw again. But when one boils a 
knife or tube it does not remain “boiled.” The slightest 
breath or touch “unboils” or unsterilizes it. 

Asepsis often seems to spell inconsistency to a be¬ 
wildered novice. Substitute the word “safety.” The 
maintenance of safety to the patient on the table depends 
on several factors: 

I. Site of Operation: 

(a) Eye: 

(1) Exposed to the elements, to dust, to 

handling, to dangerous contacts with 
others in poor or congested areas, by 
towels. 

(2) Too delicate in structure to disinfect 

with chemicals. 

158 


ASEPSIS 


159 


(3) Has enough resistance to combat a mod¬ 

erate amount of infection. 

(4) Helped by sun and air. 

(6) Throat: 

(1) Crypts full of filth all the time. 

(2) Accustomed to decay of food, intake of 

floating bacteria, etc. 

(3) Develops some immunity. 

(4) Will be exposed to same dirt again after 

operation. 

(5) Helped by sun and air, and mechanical 

washings with liquids. 

(c) Abdominal cavity and bone—or joints: 

(1) Periosteum and peritoneum most deli¬ 

cate structures—highly susceptible to 

infection. 

(2) Favoring growth of bacteria—darkness, 

moisture, and heat. 

(3) Never exposed to the enemy—never put 

up a fight—have no resistance—de¬ 
veloped no immunity. 

(4) Have no daily flushing with liquids as in 

mouth—get no help from nature. 

II. Virulence of Germs if Introduced. —Germs vary in 
virulence. It is much easier to kill some than others. 
The germs of 

Tuberculosis, 

Anthrax, 

Puerperal septicemia 

are very hard to destroy, but they are not likely to be 
found among the floating bacteria of the operating room 
or on the door knob a careless nurse might touch. A 
person coming from the tuberculosis patient to the operat¬ 
ing room builds a barrier of safety for- himself first by 
personal hygiene. A nurse must use common sense com¬ 
bined with honesty, and not develop a “phobia” about 
germs, on the principle that, by and large, in so many 
places, much less clean than the operating room, wounds 


160 


THE OPERATING ROOM 


are made and healed. To develop a balance sense of 
safety to the patient the nurse leaves all her actions open 
to criticism and advice, but thinks constantly of each 
step and its significance. 

III. The Germ's Own Choice .—The diphtheria germ pre¬ 
fers the throat, vagina, or blood-stream. There are 
others which prefer the brain and cord, leaving an ab¬ 
dominal case safe. 

Preparation of the Nurse to Comprehend Asepsis: 

I. Lessons in Bacteriology: A. Theory: (1) The nurse 
has attended lectures on bacteriology. (2) She visited the 
laboratory and saw bacteria moving on the slides under 
the microscope. (3) She sees .on the wards types of cases 
of bacteria of greater or less virulence. (4) She hears with 
awe the history of some tragic case becoming infected. 
(5) She learns the varying methods for the destruction of 
germs according to their degree of virulence, thus learning 
the relativity of the maintenance of asepsis. 

B. Practical Application to Operating Room: (1) Cul¬ 
tures should be taken from her hands scrubbed , un¬ 
scrubbed , and after handling infected material, and shown 
to her. (2) Cultures should be taken all along her trail: 
(a) after handling infected material, i. e., off whatever she 
touches, to show that she can transmit another patient’s 
infection; ( b ) after touching door knobs, faucets, etc., 
previously touched by an unscrubbed orderly or person 
from the street. (3) Dandruff, scarf skin, dust should be 
injected into a guinea-pig to show their danger. (4) Alien 
blood also as per all tests relative to transfusion. (5) 
Cultures finally from the whole operating-room force 
when it is at concert pitch, from saline, dressings, hands, 
rubber tissue, etc. (appalling when seen next day) to 
show that our best is not perfect. We cannot totally 
eradicate the menace because it is hard to control every 
act of the entire personnel. Some hospitals have a 
monitor to watch for “breaks.” Everyone should be on 
the “qui vive.” 

C. Physical culture for nurses. Straight front—no 


ASEPSIS 


161 


debutante slouch—no bumping into sterile tables—no 
miscalculation of distances. On this service a nurse should 
have a delicate set of antennae in her nervous system 
warning her when she approaches “red-hot” (sterile) 
goods. She must think with her cap, her elbows, the ties 
of her gown, knowing how wide is the margin of safety 
to keep away from the suture nurse, the tripods with 
basins, the sweep of the operator. By standing in a 
soldierly manner with the abdomen drawn in one avoids 
rubbing against what seems far enough away from the 
eyes. 

D. Ethics may be constantly inculcated by the true 
supervisor who builds for the future strong self-reliance 
of her pupil. 

E. Anatomy and physiology are constantly drawn upon 
in teaching the reasons for the extreme delicacy of struc¬ 
ture and susceptibility of joints and deep abdominal 
•cavities. 

The maintenance of asepsis is quite like good table 
manners. One handles articles with tools—the work is 
waist high, above the table—one does not carry a dish 
with the thumb over the edge of it—one does not scratch 
one’s nose—one keeps one’s elbows reasonably close to 
the sides—one does not put into the butter dish a 
fork that has passed one’s lips. It would be interest¬ 
ing for pupils to draw charts of their ideas of main¬ 
tenance of asepsis in the first and last weeks of their 
service. 

Charts of Trails. —The supervisor’s morning prepara¬ 
tion for the day’s list should include outlining, for each 
group that come to this service, a chart of the germless 
journey of the 
Gloves, 

Gowns, 

Towels, 

Sponges, 

Instruments, 

Silk, etc., 

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YA 


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clean towel, 


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Fig. 18. 


163 
























CASES 


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ASEPSIS 


167 


to the patient, used on him without being contaminated 
by anything outside of his field of operation. 

Materials that are not needed and could be used over 
again for another case are dealt out sparingly from the 
suture nurse’s table, and as she keeps clean, she may 
put’ only what did not leave her table back in the jars, 
as each patient’s blood or secretions are menacing to 
succeeding patients. 

We must, after sterilizing an article, avoid any act 
which will render that sterilization useless before it 
reaches and is used on the patient. Asepsis being main¬ 
tained means the construction of a long chain of honest, 
intently thought-out acts. 

When the surgeon makes the first nick in the skin, 
sterility ceases, but asepsis must be maintained. All par¬ 
ticipants combine to prevent anything alien to the patient 
at the field of operation from being introduced there by 
touch, breath, falling out of the atmosphere, etc. But 
the patient’s blood-stream may contain Spirochseta 
pallida, typhoid bacillus, or Streptococcus viridans, which 
faintly smeared in the wound of another would soon 
kill him. No scrubbed up person should say “I’m sterile” 
after the subcutaneous tissue is exposed. He would not 
rub a raw wound of his own along that open surface. 

Circulating nurse does not touch the ends of the forceps 
that lift the tray that carries the instruments that the 
gloved nurse drops that the surgeons use. 

Floating Bacteria. —This includes all dust or falling 
particles acting as a vehicle for bacteria. Note that 
surgeons and nurses don helmet or cap first, so as not to 
shake dandruff down on gown. 

History. —In earliest times surgeons operated without 
knowing that germs existed. The good results they did 
obtain were due to the hardihood of the race, and the 
absence of some virulent bacteria stimulated by con¬ 
gestion or civilization (so called). Later on efforts were 
gropingly made toward cleaner work by disinfecting the 
air and equipment; still results were meager. Only in 


168 


THE OPERATING ROOM 


our own lifetime has asepsis been practised, but the 
results are marvelous. Yet we may be at the peak now, 
and decline, because the personnel of olden days showed 
desperate anxiety, endurance, kindness, and concentration 



Fig. 19.—Opening towel properly folded (to the center twice). 

of effort to save the patient, while now, as we become 
pleasure-seekers, engrossed in plans for our own comfort, 
we undermine the scientific skill of the surgeon and 
pathologist, who build up the delicate sensitive structure 
on which they have to rely. One nurse’s “little(?) white 








ASEPSIS 


169 



lie,” acted or spoken, can wreck the whole fabric, injuring 
the professional standing of surgeon and hospital. It is 
gravely necessary to lay emphasis upon constant truth¬ 
fulness in all our educational schemes. Otherwise only 


Fig. 20.—Laying a sterile towel by the field of operation, opened 
only after passing the surgeon. 

the grimmest prophecy can be made for the operating- 
room results of 1934. The only way to train a nurse to 
be “conscientious” is to be close to her and to know 
intuitively as well as to see that she works honestly. 






170 


THE OPERATING ROOM 


Definition of Technic. —This word has unfortunately 
been written into the nurses’ argot. It must be left to its 
proper place, i. e., the anatomic procedure of surgeons in 
type operations; where to cut—how long the incision— 
when to ligate—or excise—how to dissect, etc. The tech¬ 
nic of a violin virtuoso consists in his mechanical style 
of execution of the scientific knowledge of scales and chords 
—following a set piece. The sentiment he puts into it 
corresponds somewhat to the natural acute diagnostic 
sense of the surgeon. There cannot justly be said to be 
a “break” in technic. The nurse may make a “break” in 
the aseptic chain. 

Break in Asepsis. —If any scrubbed person inadver¬ 
tently touches an unsterile object, such as the outside of a 
dressing cover, or the circulating nurse’s gown—on ad¬ 
vice of counsel, she should 

(1) Wash her gloves in alcohol + sterile water, or 

(2) Change her gloves, or 

(3) Drop out, as the case may be, 
counsel deciding the degree of necessity, as, 

(1) The article touched likely carried no patho¬ 

genic micro-organisms (or few). 

(2) Such as were there may be destroyed by mod¬ 

erately powerful disinfectants. 

(3) The operation should not be delayed if the pa¬ 

tient is in poor condition due to 
(a) Longer anesthesia, 

C b ) Longer exposure of intestine. 

(4) Of two evils, the less is chosen, i. e., 

Effort at hasty disinfection. 

(5) The patient’s degree of resistance to some 

moderate degree of infection is known to the 

surgeon. 

The supervisor discussing points of this sort is spending 
these moments well. Hurried replies, incomplete ex¬ 
planations, leave much to the pupil’s untrained imagina¬ 
tion. Probably she becomes callous to these niceties of 
honor. A safe rule is “take nothing for granted.” 


ASEPSIS 


171 


The Pin. —When pins are removed, a package is con¬ 
sidered unsterile. Who knows what hand has opened and 
uncovered the dressings, handled them, and rolled them 
up again? The pin is buried in one insertion—no part 
exposed but the head. 

• i i Wrong method, 

in out in 

If the out were smeared with red ink, and the pin 
quickly withdrawn, there would be some redness on the 
dressings inside. Similarly, if the “out” were contam¬ 
inated when handled by unscrubbed hands, the with¬ 
drawal of the pin would infect the contents. Some in¬ 
stitutions use no pins, simply rolling the fourth corner 
inside tightly, especially in drums. 

Preparation of Nurse for Assisting at Operation in 
Private House. —For many reasons operations may have 
to be done in the home: (a) Contagion; (6) patient can¬ 
not be moved; (c) patient too far away from hospital; 
(d) patient afraid of hospitals; (e) privacy essential; (/) 
patient’s choice of operator not permitted use of nearest 
operating room. 

No matter what the relation between operator and 
hospital, a graduate nurse must say nothing to divorce the 
patient from the operator of his choice. If conditions are 
such that she cannot tolerate them, in the light of her 
conscience, she should ask to be relieved. In a private 
house, with “no anything” of a technical nature, the 
nurse must make haste, filter saline, clean the room, etc., 
and being alone, she may open as many packages as 
needed before she scrubs. Hospital training should 
equip for competent private work. Every directress of 
nurses should do two years of private work so as to know 
for what she is training her pupils in future. 

To assist a doctor alone, she may take out the contents 
of packages with a long uterine dressing-forceps, kept in 
lysol \ per cent, without scrubbing up herself, or may 
lay them per forceps on the table in generous quantities. 



172 


THE OPERATING ROOM 


and then scrub. Where duties are not clearly circum¬ 
scribed, some nurses are too ready to get into a sterile 
outfit and then ask for slavish attendance. The scrubbed 
nurse should defer putting manacles on herself till the 
latest moment, and should do all she could alone, both 
before and after. Her brain should plan all ways to pre¬ 
pare layouts, to “make the room safe for asepsis.” 
“Every tub should stand on its own bottom” is a true 
though homely adage. Forethought and self-reliance are 
two things thus developed which “this sad world needs.” 

Directions for Scrubbing Up. — Nurses’ Scrub for Lap¬ 
arotomy .—Place soap bottle, brush, and orange-wood stick 
under running water in a basin controlled by a pedal. 
Soap the brush and scrub each arm to the elbow half a 
minute. Rinse. Soap brush, and scrub wrists, backs and 
palms of hands, knuckles, finger-tips, and between all 
fingers very thoroughly, with a stout lather, following the 
outline of the whole hand and both surfaces. Clean nails, 
push back cuticle, soap brush, scrub, and rinse. Soap 
brush and scrub hands all over for one minute more. 
Total eight minutes. Rinse under running water. Never 
touch stand. Make paste of lime and soda and rub in 
well up to elbow one minute. Rinse. Soak hands in 
HgCl 2 1 :5000 two minutes. If the soap is not entirely 
rinsed off, the nails grow brown and the skin cracks. 
Some hospitals disapprove of the brush on a nurse’s arms 
above the wrist, which makes the skin susceptible to 
bichlorid rash and renders her unfit for duty. 

Tonsil Scrub .—Scrub hands and wrists with soap for 
three minutes in running water. Rinse. Soak in bichlorid 
1 :5000 for one minute. Brushes of medium fine hair, 
never fiber. 

General Addenda: 

1. Solutions must not become clouded. Scrub up 
stand kept wiped up. Fresh solutions. 

2. Brushes washed and boiled after each case—thor¬ 
oughly sunned or dried in driers. Plenty of brushes, 
sunned, cheaper than a few, dried by drier—saves bristles. 


ASEPSIS 


173 


3. If a nurse has to wipe perspiration off a surgeon’s 
face she winds a clean hand towel around her right arm 
spirally to leave no loose end, and as he leans away from 
the table, she wipes very firmly and slowly, with deep, 
systematic strokes, not faint, tickling dabs. (See Fig. 4, 
p. 40.) 

4. Operator’s glasses must not be disturbed. If they 
are spattered with blood from a spurter, the nurse should 
remove them instantly, wash in cold water, then alcohol, 
to disinfect and polish. 

5. Keep ready boric acid and argyrol in case of pus in 
the eyes. 

6. The variance in time limits for sterilizing goods is 
due to the varying durability of goods, mildness of bac¬ 
teria, and amount of resistance of the part where used. 

7. Breaks in maintaining asepsis can be made by 
others than nurses, e. g., by the assistant if he lets the 
laparotomy sheet sweep the floor. It should be dis¬ 
carded. 

8. In wiping the abdomen with iodin, the umbilicus is 
done last of all, and the sponge stick discarded. 

9. When a nurse sets up alone, she may lift a basin out 
by the under surface and support it from below at the 
faucet, or fill it afterward by a pitcher. 

10. Germs travel through moist goods. Covers must be 
entirely removed from a table which has had contact with 
the patient. It is not enough to peel off the top layer. 
For every operator there should be two covers on the 
suture table, thick first to protect glass from heat and to 
deaden sound, thin on top. 

11. Suppose the surgeon used a side table, it would 
have to be washed, and wiped with 5 per cent, carbolic 
acid, then dried before using for a second case. 

12. No lower shelves should be used.. The awkward¬ 
ness is dangerous. 

13. The room should not be set up too long before 
operation. There should be a standard ruling. When a 
floating night nurse comes on duty at midnight, she may 


174 


THE OPERATING ROOM 


set up about 7.30 a. m. for early cases. Sterile goods do 
not remain so if opened for a long time. 

14. No person on the force should approach the suture 
table except the suture nurse. 

15. A clean case is that which will not menace the 
operating room, and in which we expect normal tem¬ 
perature and primary union. It is usually sewed up 
tight. Such would be gynecologic repair, appendix in 
interval and not ruptured, plastic work, fibroid tumor of 
uterus, compound fractures, etc. 

16. In a clinic the clean cases come first, e. g., gastro¬ 
enterostomy. 

17. All apparatus for the anesthesia room should be 
changed* and sterilized. It is just as harmful to transfer 
tuberculosis bacilli per os as to carry external infection 
to the abdominal cavity. Coughing may ruin a hernia 
operation. 

18. If jar lids must be laid down, they are laid top 
down. 

19. Instruments used for amputation within the ab¬ 
dominal cavity, e. g., to cut off appendix or sever pedicle 
of a cyst, are discarded with the specimen. 

20. Towels in contact with pus or malignant growths 
that bleed are gathered and soaked in disinfectant. 

21. The operating table should be washed and whitened, 
then disinfected in all crevices daily, and after discharges 
from dirty cases. 

22. Shoes—to secure efficiency the head nurse will 
watch that the nurses wear suitable shoes, owing to their 
enormous degree of fatigue—and this means no dressy 
street shoes. 

23. Holes in gloves and towels or sheets constitute a 
break in the maintenance of asepsis. 

24. Tapes and buttons must be used to keep gowns 
snug and in good repair. 

25. When a glove is punctured, it should be discarded, 
the hands disinfected, and new gloves put on. 

26. Wet gloves are cheaper. Dry sterilization ruins 


ASEPSIS 


175 


rubber. Surgeons are expensive. Wet gloves ruin their 
temper. 

27. Certain drugs must not be heated, others only for 
a limited number of minutes, to sterilize. The pharma¬ 
cist must issue a code regarding cocain, novocain, ad¬ 
renalin. 

28. A bottle of aristol may be wound (with arm) in a 
bichlorid towel, after the top is wiped off, to be shaken 
over a line of sutures (by permission of the surgeon). 

29. A general concerted effort toward simplification of 
methods brings success. An operating room cannot suc¬ 
ceed if weighted down with the idiosyncrasies of several 
surgeons. 

30. One surgeon alone on a staff is entitled to idio¬ 
syncrasies only by the unanimous vote of the whole staff. 


CHAPTER X 


FORMULA AND DIRECTIONS 

“Formula and Preparation of Dakin’s Solution (Ameri¬ 
can ]\/[edical Journal, 1916). 

“To the Editor: The formula for the preparation of Dakin’s 
solution, which you give in the Journal, October 7, 1916, has recently 
been superseded by the following, which I obtained from Dr. Carrel 
at Compiegne last May. The unsatisfactory results sometimes 
obtained by the original preparation, and the disfavor which it has 
acquired in the hands of some surgeons, are probably due to im¬ 
perfections in the product, such as the persistence of alkalinity. 
Some of the wounds which I saw in various hospitals under the 
treatment were brown and unnatural in appearance, while all at 
Compiegne were rosy and apparently entirely free of pus. The 
wounds were there kept constantly wet with the solution, which was 
introduced through tubes and poured on the surface every two hours. 
It is desirable that the determination of its value should not be 
delayed by defects of preparation, and you may therefore think it 
worth while to publish this formula (Lewis A. Stimson, M. D., 
New York). 

“Preparation of Hypochlorite Solution (Dakin).: 

1. Chlorinated lime (bleaching powder), 200 gm. 

Sodium carbonate, dry, 100 “ 

Sodium bicarbonate, 80 “ 

2. Put the chlorinated lime in a 12-liter flask, with 5 
liters of ordinary water, and let it stand over night. 

3. Dissolve the sodium carbonate and bicarbonate in 
5 liters of cold water. 

4. Pour (3) into the flask containing (2), shake it vigor¬ 
ously for a minute, and let it stand to permit the calcium 
carbonate to settle. 

5. After half an hour siphon off the clear liquid and filter 
it through paper to obtain a perfectly limpid product. 
This must be kept protected from the light. 

“The antiseptic solution is then ready for surgical use; 
it contains about 0.5 per cent, of sodium hypochlorite with 
small amounts of neutral soda salts; it is practically iso¬ 
tonic with blood-serum. It should meet the following tests: 

176 


FORMULAE AND DIRECTIONS 


177 


“Test .—Put about 20 c.c. of the solution in a glass, and 
pour on its surface a few centigrams of phenolphthalein 
in powder; shake it with a circular movement as in rinsing; 
the liquid should remain colorless. A more or less marked 
red discoloration indicates the presence of a notable 
quantity of free alkali, or incomplete carbonation, im¬ 
putable to an error in technic. 

“Errors to be Avoided .—Never heat the solution. If in 
an emergency it is necessary to triturate the chlorinated 
lime in a mortar, do so only with water, never with the 
solution of the soda salts. 

“Trituration .—To 10 c.c. of the solution add 10 c.c. of 
distilled water, 2 gm. of potassium iodid, and 2 c.c. of 
acetic acid. Pour into this mixture a decinormal (2.48 
per cent.) solution of sodium thiosulphate (hyposulphite) 
until it is decolorized. The number of cubic centimeters 
of thiosulphate employed multiplied by 0.03725 equals 
the percentage of sodium hypochlorite in the solution.” 

Thiersch’s Solution. —A valuable antiseptic for nose and 
throat. 

Salicylic acid, 2 parts 

Boracic acid crystals, 12 “ 

Water, 1000 “ 

Used by some surgeons during operations and as a dressing 
solution. 

Formulae for Iodoform Packing: 

I. New York Post-Graduate Hospital—stainless, fadeless. 

Iodoform powder. 5xxj 

Glycerin. 5xxj 

Alcohol.q. s. ad. Oiv 

Sterilize. Keep in clear glass jars lined with waxed paper, which 
may be sterilized like gauze. 


II. New York Eye and Ear Infirmary: 

Iodoform powder. 15 c.c. 

Normal saline.. 120 “ 

Carbolic acid solution (5 per cent.). 5j 

Tincture green soap. 5ss 

Glycerin. 5 ss 

Sterilize in open jars for twenty minutes at 15 pounds, 
beside jars and inverted, in the dressing sterilizer. 

12 


lids 










178 


THE OPERATING ROOM 


III. Iodoform powder. §ij 

Tincture green soap. S iij 

Water distilled.. 3vj 

Soak gauze in solution, wring dry, sterilize in open jars for thirty 
minutes at 15 pounds. 

IV. Iodoform powder. 3 iij 

Ether. Oiij 

Stir well. Soak, wring dry, then scrub up and proceed as in 
Formula V. 

V. Ten per cent, iodoform gauze. Sterile cotton plugs, or sterile 
rubber caps for tubes. 

Iodoform powder. 1 part 

Sterile glycerin. 4 parts 

Alcohol, 95 per cent. 5 “ 

1 in 10 = 10 per cent. 


Also gauze packing or bandages, with sizing thor¬ 
oughly washed out, before using. 

2 Round basins, 

1 Sound for packing tubes, 

1 Pair scissors. 

Marble or glass slab—sterile towels. 

Nurse scrubs up and places above named sterile articles 
on sterile table. 

Fill one basin with bichlorid of mercury 1 : 5000. 

Wring gauze out of bichlorid, and pass it into the other 
basin, containing iodoform mixture, rubbing it in well, and 
equally throughout. Sterilize. 

VI. Iodoform powder. 3 j 

Water (distilled).. 3d 

Tincture green soap. 3 iij 

Gauze. 12 yards 

Mix well, rub thoroughly into gauze; sterilize thirty minutes at 
15 pounds, or 250° F. Keep in tubes or jars. 

VII. Iodoform powder. 3v 

Glycerin. 5 j 

Bichlorid of mercury solution (1 : 1000).... 3v 

Sterilize in test-tubes with cotton plugs and muslin cover for 
twenty minutes at 15 pounds. 


Gauze for packing should be fine, smooth, and perfect. 
It should be previously drawn, raveled or folded, in odd 
















FORMULAE AND DIRECTIONS 


179 


half-hours in the anesthetic room, while waiting, etc. It 
must be clean. Bandages are raveled at the ends, to 
leave smooth, threadless borders, because loose threads 
left at time of removal act as a foreign body in a granulat¬ 
ing area. The fuzz must be snipped off so that the re¬ 
maining part will exactly measure J, 1, or 2 inches, when 
spread out single, as labeled. Plain gauze packing is 
sterilized once more, in muslin covers, or in open jars, in 
12-inch to 5-yard strips for ear, uterus, rectum, osteo¬ 
myelitis, carcinoma of cervix, etc. 

The drugs of the formula are mixed with a sterile 
spatula in a sterile glass graduate or bowl, using a sterile 
minim glass to measure small amounts. Pour into a flat 
glass basin, also boiled. Emulsify powder thoroughly in 
the green soap and glycerin before adding the aqueous 
solutions. No stain is left on glass utensils, hence they 
are an advantage. 

Catgut. 1 —I. Wash tubes with soap and water—rinse— 
soak in bichlorid of mercury 1 : 2000 for two hours—put 
in sterile glass jars and cover with bichlorid solution. 

II. Boil tubes of catgut and let stand in Harrington’s 
solution, with a gauze compress to cover them, under the 
lid of the jar. 

Much blame for infection is laid on the catgut, where 
it may be justly placed on the technic in preparation for 
the operation. Catgut should be made from the intestines 
of range lambs which are least susceptible to tetanus or 
anthrax. 

Surgeons’ Silk.—This should be threaded in 15-inch 
lengths, in all grades of strength, on all needles suitable 
for wounds requiring silk, and then run through a hemmed 
square of white flannel, afterward dry sterilized, but not 
too often (dry method rots silk, more than boiling). 
This saves the trouble of threading during an operation. 

Silkworm-gut.—Must not be handed for a lip or other 
delicate surface. 

Bone Wax.—Boil wax in its container, with cover 

1 See Dr. Brickner’s comprehensive work, The Surgical Assistant. 


180 


THE OPERATING ROOM 


separate, for twenty minutes, then cool, cover, and wrap 
in a sterile towel to be carried about. When it is the 
hobby of one surgeon, it is carried by him to the various 
hospitals where he operates. 

Vaselin. —Prepare similarty. 

Aluminum Acetate Solution: 

Plumbi acetate 

Alumen. .*. 

Aqua. 

Mix and filter. 

Dilute when using with five to eight times as much 
water. 

Never use it full strength, as it macerates the skin. 
The ingredients are very costly, and the amount must 
be carefully estimated. For a small spot to be kept wet 
with a small gauze dressing, e. g., a redness, the size of a 
half dollar on a leg, about a half pint is enough to make 
up at once of 1:8 aluminum acetate. Use a sterile 
basin, and sterile water, with aseptic precautions. If 
about one-half pint, say gix, be needed, of 1 : 8 solution, 
then only of aluminum acetate is taken, and sterile 
water added, 5viij (one to eight = one in nine). This 
keeps down the patient’s drug bill. Moisten the gauze, 
lay it loosely on the spot, then lay the limb on a towel 
and rubber sheet, then cover with a high cradle to let air 
circulate and evaporation take place, causing reduction 
of temperature. Do not envelop limb in rubber. 

Boric Acid Solution: 


Boric acid (crystals preferably). 4 parts 

Water. 100 “ 


Boil till clear. To use, add an equal amount of sterile water 
(2 per cent.). 

Pharmacists employ the cold process by adding the 
powder to cold water and letting it stand and absorb 
until a sediment of boric acid lies at the bottom (super¬ 
saturated). 

Normal Saline. —Salt exists in the blood in the propor- 


... 3.5 
... 9.0 
ad. 100.0 







FORMULAE AND DIRECTIONS 


181 


tion of 9 parts to 1000, or 9/10 per cent. It is not neces¬ 
sary to say to an intelligent person 9/10 of 1 per cent., 
it is to be hoped. Saline solution is called normal when 
it contains as much salt as blood does. 

TJses of normal saline: 

Douches of eye, nose, mouth, throat, rectum, 
perineum, 

Hypodermoclysis, 

Hypodermic with local anesthetics, 

Intravenous infusion, etc. 

A patient should get normal saline to take the place 
of blood lost in hemorrhage to tide him over, till, with 
the ingestion of food, he soon makes more new blood. 
Saline is a stimulant after shock. 

How to make normal saline. 

I. One quart of blood or normal saline = 32 ounces = 
256 drams = 15,360 grains. 9/10 per cent, (determined 
by pathologists) of one quart = amount of solid salt. 
9/10 of 1/100 of 15,360 grains = 138 grains. (Salt in 
one quart blood or saline.) 

In every quart of water place 138 grains prepared salt, 
and boil thoroughly for five minutes, skim, measure, and 
add enough sterile water to restore to the proper number 
of quarts, some having evaporated. Cool. Filter through 
sterile cotton and sterile filter-paper, coarse, then fine, 
regularly plaited to fit into a sterile funnel, into a set of 
Florence flasks of 1 pint, 1 quart, or 2 quart sizes. Florence 
flasks are cleansed by bottle brush, tincture of green soap, 
sterile water, rinsing, alcohol and final rinsings, then 
stoppered with sterile cotton plugs till needed. 

II. Salt may be prepared in tablets of the required 
weight, and these are dissolved in distilled water. Every 
hospital may have a distillation outfit for use of the 
operating-room and the pharmacy. It may be tucked 
into the sterilizing room. Distilled water should be 
collected daily and used at once. If kept under aseptic 
conditions, it will minimize bacterial activity in the 
solution. 


182 


THE OPERATING ROOM 


I AND II 

To transfer saline solution to the flasks, the nurse 
should “set up” a sterile table with sterilized cotton, 
towels, gauze, tapes to tie, utensils and hands scrubbed 
as for operating. The round body only of the flask is 
filled, then all are set on the floor of the dressing sterilizers 
for one-half hour at 15 pounds, on three successive days, 
care being taken to tag them as they come out, as being 
done by such a nurse, and once, twice, thrice. If at any 
time a cloudy growth or crystals are seen in the flasks, do 
not use the solution. The brilliant clarity of well-made 
saline is a mark of distinction in a good operating room. 

Bichlorid of Mercury Solutions.—Here is where a 
teacher of arithmetic shines in a training-school. It is 
not enough to ornament the walls of lavatories with printed 
instructions. At the end of the probation period, every 
nurse should be able to teach all other nurses for all time 
to come, why 7J grains to a pint makes a 1 : 1000 solution. 
Pathologists have found that many pathogenic bacteria die 
(not all) in solutions of many of the common drugs used 
for germicides, of the strength of 1 part of the drug to 
1000 parts of water. In estimating we want common 
measures, such as pints, or thousands of units. 

One pint = 16 ounces = 128 drams = 7680 grains. 

A germicidal solution of 1000 parts has 1 part of the drug. 

A germicidal solution of 1 part has 1/1000 part of the 
drug. 

A germicidal solution of 7680 parts or grains will there¬ 
fore have Yq q ~ q or 7§ (almost exactly) parts or grains of 
the drug. 

Therefore, 7| grains of any drug dissolved in 1 pint of 
water makes a 1 :1000 solution of that drug. 

* * * * * * 

A man against 1000 foes has not much chance. Against 
2000 foes he is only half as strong. A solution called 
1 : 2000 is only half as strong as 1 : 1000, because the 1 
is the man (or drug) and the 1000 or 2000 is the foe (or 


FORMULAE AND DIRECTIONS 


183 


water). To make a 1 : 2000 solution we add twice as 
much water, 2 pints, to 7J grains (unchanging amount) 
of the drug. 

Never Break a Tablet. —The actual dose may be all 
in one end and only milk-sugar in the other. Dissolve it 
entirely in an exact measure of water and take half the 
liquid, if required. 

1 :500 is stronger than 1 : 1000. A man has twice as 
good a chance with only 500 foes as with 1000. If 1\ 
grains in 1 pint make a 1 :1000 solution, then we double 
the dose of bichlorid and keep the amount of water un¬ 
changed to make twice as strong a solution. Note that 
1 :500 cauterizes. It is used to brush lightly under the 
lids in trachoma. It will stiffen the -hands, maceration 
following, being an escharotic. 

Bichlorid of mercury deteriorates very fast, therefore 
should be used only in small quantities. Where required 
weak, it is very economical to keep a stock bottle of 
1 :1000 solution, made up daily. Stronger stock solu¬ 
tions are dangerous, being often measured too hastily. 

How to compute for a douche. 

Total amount needed for vaginal irrigation, 4 quarts. 

Strength 1 : 6000 ordered. 

One to six thousand solution is five times weaker than 
= six times as weak as 1 :1000 solution. 

One ounce of 1 : 1000 plus 5 ounces of water = 6 ounces 
of 1 : 6000. 

One-sixth of 4 quarts or 128 ounces = 21J ounces. 

128 — 21J = 106f ounces. 

Take 21J ounces of 1 : 1000 solution and the balance 
of sterile water or 1 pint, 5| ounces drug solution to 
three quarts, lOf ounces sterile water. 

Another name, corrosive sublimate. 

In some institutions a saturated solution is made 1 :16, 
from powder, and from this, as the nurses work, they make 
their solutions by taking 2 drams for every pint of 1 : 1000 
solution needed. 

1/16 of 3 ij = 1/16 of 120 grains = 7^ grains (as above). 


184 


TH^ OPERATING ROOM 


Whenever a nurse makes up a solution, she should 
present the arithmetical explanation on paper to the 
supervisor for endorsement. 

Colors. —Hospitals should all have standard colors for 
certain solutions to act as a check on absent-mindedness. 
To have a uniformity in this everywhere would assist 
nurses, who usually remain only about two years in one 
institution. 

Tables: 

A. Troy weight: 24 gr. = 1 dwt. 

20 dwt. = 1 oz. 

12 oz. = 1 lb. = 5760 gr. 

B. Avoirdupois weight: 16 drams = 1 oz. 

16 oz. = 1 lb. 

25 lbs. = 1 quarter 

4 quarters = 1 hundredweight (cwt.) 

20 cwt. = 1 ton. 

C. Apothecaries' weight: 20 gr. = 1 scruple 

3 scruples = 1 dram 

8 drams = 1 oz. 

12 oz. = 1 lb. = 5760 gr. 

D. Apothecaries' measure: 60 minims = 1 fluidram 

8 drams = 1 fluidounce 

16 oz. = 1 pint—symbol O (octarius) 

2 pts. = 1 quart 

4 qts. = 1 gallon—symbol C (congius) 

Symbols: 

Degrees, °. Minutes,'. Seconds, ". 

Abbreviations: 
i. e. = that is, 
viz. = namely, 
e. g. = for instance, 
ibid. = the same, 
etc. = and so forth. 

Formaldehyd. —This is a gaseous substance, valuable 
as a disinfectant, to fumigate a room after contagion, by 
generating in large quantities with a force pump at the 
keyhole, or with candles inside the room, or in small 
quantities in a cabinet of bougies or cystoscopes which 
cannot be disinfected in any other way. 

It is soluble in water in the proportion of formaldehyd 
40 parts to water 100 parts. 


FORMULAE AND DIRECTIONS 


185 


This solution is called formalin. Other fluids are sold, 
such as formacal, having the same ingredients practically, 
yet not daring to use the original trade name which has 
commercial rights. 

Formalin is measured just like lysol, milk, or carbolic 
acid. When we say formalin we consider it an original 
substance. Forget about how it is derived. Formalin 
solution 4 per cent, means 4 parts (oz. or drams) out of 
the formalin bottle to 100 parts (oz. or drams) of water: 

Formalin 4 per cent, is particularly suited to the 
preservation of specimens, particularly the EYE. The 
laboratories ask for formalin. It does not shrink or 
harden* delicate tissues. Alcohol ruins an eye specimen. 
Yet formalin hardens satisfactorily for section cutting. 
Specimens must be placed in wide-mouthed bottles with 
good new corks, to prevent evaporation and concentra¬ 
tion of the drug, with consequent destruction of the 
tissue. Use it sparingly. It is hard on the eyes and the 
skin of working nurses, also expensive. 

Nitrate of Silver. —This is best handled in tablets. 
They deliquesce when exposed to air, and deteriorate in 
light, therefore are best kept in a dark blue or brown bottle 
tightly stoppered with cotton and glass. The printed 
directions must be read very, very carefully. There is a 
tremendous difference in strength between gr. v, and gr. 
.5. Grains v is a tablet ten times as strong as gr. .5 (|). 
A bladder irrigation, based on this mistake, causes pain and 
tenesmus, by reason of its caustic effect on the mucous 
membrane. In handling dangerous drugs one should 
consult with a supervisor. 

Percentage Solutions: 

In both Troy and Apothecaries’ Weight, 480 gr. = 
1 ounce. 

In Apothecaries’ Measure, 480 minims = 1 fluidounce. 

We say, frequently, 4-f- gr. to the ounce (roughly, 5 
gr.) make a 1 per cent, solution. 

Why is this? 

One ounce of a drug is 100 per cent. pure. 


186 


THE OPERATING ROOM 


If one oz. 100 per cent, pure = 480 grains (dry) or 
minims (fluid measure); then 1 per cent, pure = 1/100 
of 480 = 4f gr. (dry) or minims (fluid). 

The discrepancy of saying 5 gr. to the ounce is not so 
small as to be negligible, as pharmacists must calculate 4f. 

Then, 2 per cent, solution = 10 gr. or minims of drug 
to 1 oz. water; 10 per cent, solution = 100 gr. or minims 
drug to 1 oz. water. 

Eye solutions of homatropin, argyrol, etc., are almost 
all estimated in percentages or grains to the ounce, be¬ 
cause they are very powerful as well as expensive. Nurses 
should not dispense, as they usually are notoriously poor 
in arithmetic, like nearly all other women. It sha’kes the 
confidence of physicians and patients to see a nurse han¬ 
dling powders, etc., in a drug room. 

Ringer’s Stock Salt Solution: 

Sod. chlor.. 150 oz. Troy 

Calc, chlor. 244.5 gr. Troy 

Potass, chlor. 159 gr. Troy 

Aqua destillata.q. s. ad. 5 gals. 

Use 4 fluidounces of this stock and 28 ounces distilled water. 
Filter through filter-paper into Florence flasks. Plug with ab¬ 
sorbent cotton and gauze. Boil twenty minutes. 


Harrington’s Solution: 


Alcohol, 95 per cent. 1600 c.c. 

Hydrochloric acid. 150 “ 

Aqua destillata. 750 “ 

Corrosive sublimate. 2 gm. 


Color with gentian violet (if this fits in with hospital scheme 
for drug colors). 


Bismuth Gauze Drains: 

This stimulates granulations and old sinuses. 

Bismuth subnitrate. 5ij 

Glycerin. § ij 

Warm water. Oij 

Mix thoroughly adding, warm water gradually. Stir continually 
to make a fine emulsion. Pass gauze through it three times, then 
wring out, dry, cut in strips, pack loosely, with aseptic precautions, 
and sterilize at 7 or 8 pounds’ pressure for thirty minutes. 













FORMULAE AND DIRECTIONS 


187 


Rubber Goods. —A. Tubing. —T-tube, used in vaginal 
punctures, a T made of two pieces of rubber tubing cut 
in a special manner. The cross-piece does not act as a 
drain. It merely holds the tube in position, therefore 
the end of the stem must be open. Do not boil with 
instruments. Do not let lie in the same cabinet with 
silver. 

Provide safety-pins for keeping straight tubes from 
disappearing into the wound. 

Tubing is bought in small quantities, owing to its perish¬ 
ability (three months). It is needed in different lengths, 
lumen, and firmness, as well as thickness of wall. It must 
be of first-class quality and odorless. Second-grade 
rubber, made from old galoshes and automobile shoes, 
smells bad. Keep in lycopodium powder in a cool cellar. 
When boiling, wrap it in old muslin to keep off the scum 
of the water. Boil for ten minutes and transfer to a 
clean boiled jar of 5 per cent, carbolic acid. It is used 
for gall-bladder, empyema, intestinal obstruction, and 
ruptured appendix operations. Statistics for the past 
three months on amounts used serve as a guide in 
buying. The cloth foundation must never show 
through. 

B. Rubber-dam .—Thin sheets of pure Para rubber, 
non-irritant, are needed in cases such as empyema, 
where it is difficult to maintain tubes in position, or open 
wounds high up in the intestinal tract. 

C. Rubber Spools .—Much used for empyema, propped 
against the bony structures inside. 

D. Rubber Tissue. —(Gutta-percha.) 

To cleanse and sterilize : Lay on a cold glass slab, scrub 
with small boiled brush, with tincture of green soap and 
cold water on each side. Rinse thoroughly under faucet. 
Soak over night in bichlorid of mercury 1 :500. Second 
day: Lift with sterile forceps or scrubbed hands into 
basin of sterile water, fold in dry sterile towels till dry. 
Sterilize in dressing sterilizer for twenty minutes at 15 
pounds, with gauze sheets between the layers of tissue. 


188 


THE OPERATING ROOM 


This is used mostly for 

(1) Cigarette drains, 

(2) Like rubber-dam, over plastic work such as 

grafts, 

(3) Over burned areas. 

It does not stand frequent sterilization or age. The 
supply must be dated, and never allowed to become 
friable, as it is called for at critical junctures. It is never 
pinned, merely closed in folds. Mucilaged labels are in¬ 
expensive and business-like. Flour-paste labels are made 
by dissolving 1 teaspoonful of flour in 1 cup of cold water 
and boiling till clear. 

Some hospitals keep rubber tissue in sterile glass jars 
lined with sterile waxed paper which can be heated with 
the rubber in the sterilizers. 

Other institutions keep it wet in bichlorid of mercury 

1 : 1000 . 

E. Rubber Gloves. —I. In buying gloves the operating- 
room supervisor’s statistics, if correct, are very valuable. 
The glove must be regarded as one of the institution’s “long 
arms of efficiency.” It is the most fertile source of anger 
and jealousy. Those concerned should sit down together 
and frame a policy on gloves, in an unimpassioned hour, 
and abide by it, as follows: 

(1) Who may have gloves at .all? 

(2) Who may always have new gloves? 

(3) Who will buy the gloves? 

(4) Shall the gloves be boiled and put on wet or 

dry—sterilized? 

(5) Shall the obstetricians receive the same con¬ 

sideration as surgeons? 

(6) Who shall clean and repair gloves owned and 

brought by the surgeons? 

If all hospital administration were based on the welfare 
of the patient, snags could be easily avoided. Favoritism 
frequently occurs. A young man, not yet famous, is put 
off with old gloves with holes, or loosely flabby, or over¬ 
mended, when he has to palpate an on-coming head in a 


FORMULAE AND DIRECTIONS 


189 


delivery, whereas a prosperous older man is given brand 
new lively gloves for a carcinoma case. Standing on the 
merits of the cases, the new clean baby is a bigger asset 
to the community than the wrecked life of the old car¬ 
cinoma case. 

II. Records must be kept of the sizes, idiosyncrasies, and 
“wet” or “dry” of all operators, including visiting sur¬ 
geons. It is the beginning of success to win a smile from 
a great surgeon by handing him the correct gloves, if he 
has been there once before, or if the size has to be tele¬ 
phoned for. Interns must find their size when coming 
on the service and record it. Scrubbing nurses (on su¬ 
tures) must be satisfied with mended gloves (unless in 
bone-plating, etc.) because they merely pass goods. 

III. Responsibility for proper arrangement in pack¬ 
ages is taken by the nurse who puts up gloves for clinics, 
by signing a slip which goes with them. 

IV. Arrangement .—When a surgeon operates, the drum 
contains gloves for him, his two assistants and, the suture 
nurse. In case he spoils a pair, they may be replaced by 
separate packages outside the drum in reserve, of the 
correct size. 

V. To Put Up. —(a) Gloves are carried after the 
operation in a basin to the hoppers. Wash in cold water 
to remove blood, K. Y., vaselin, or pus. Squeeze out the 
air, wrap in old muslin, and boil five minutes. Lift out, 
test with cold water for holes, classify as good and bad, 
and hang on the glove-tree. Turn and dry both sides. 
Send to the workroom in two lots. 

( b ) The glove mender blows up the glove, locates the 
hole, wets it slightly in a doubtful place to see if bubbles 
form (Fig. 21). To blow up a glove, twirl it by the wrist 
stretched taut with forefingers, catching the wrist tight, 
and forcing the air up into the digits. To mend—roughen 
the edges of the hole with sandpaper or a nail file. Cut 
the patch oval shaped. Clean the two areas with benzine. 
(Special permit from fire department to keep on the 
premises.) 


190 


THE OPERATING ROOM 


Apply Pure Gold or other rubber cement to the glove, 
press the patch on, keep it there with warm hand pressure, 
then lay under a press. Powdery gloves will not mend. 



Fig. 21.—Detecting holes in a glove. 


If any part overdilates, mark it poor. Do up a package 
of powder with gloves. 

(c) To Powder Gloves .—Shake a quantity of unper¬ 
fumed talc powder into a gallon basin. Set it on the 


FORMULAE AND DIRECTIONS 


191 


work table. Sit on a very high stool’ and get plenty of 
purchase to press downward. Pass gloves through 
powder twice (turned) squeezing them down into the un¬ 
yielding basin. Fold back the cuffs till they are only 
wrist length (short), so that the scrubbed hand of the 
surgeon may take the glove by its inside. (See chapter on 
Asepsis.) Put up in covers, and sterilize in drums for 
fifteen minutes at 10 pounds, or whatever the hospital 
formula specifies. 

F. Rubber Aprons, etc. —Aprons are soaked in bi- 
chlorid of mercury 1 : 1000 before operation. After 
operation they are scrubbed with cold water, tincture of 
green soap and brush, rinsed well, painted with 5 per 
cent, carbolic acid solution, dried over a bar, and pow¬ 
dered with lycopodium. All flat rubber should be kept 
rolled on a Hartshorne roller under the edge of a counter 
or shelf. 

Douche bags (seldom found now in hospitals) are boiled, 
rinsed, and left to hang inverted. Oil for enemata must 
be administered per funnel, not bag. 

G. Hard Black Rubber. —This must be kept in cotton- 
lined boxes in order not to chip or break. If roughened 
the least bit, it will injure the part. It is cleansed 
with cold water, soap, bottle or tube brushes of proper 
caliber, and 5 per cent, carbolic acid. Black hard rubber 
must not be boiled. It may be disinfected in a fumigating 
cabinet. Heat alters the shape of a pessary or tracheotomy 
tube, and this may hold up that most urgent of all opera¬ 
tions. 

H. Rubber Catheters .—(1) Plain. These should be kept in 
a very long flat box in a cool place in lycopodium powder. 
This box has compartments for the many kinds of cath¬ 
eters, to show at a glance when one stock is low. The 
box is locked and the key kept with the general operating- 
room keys. These things may not be wanted often, but 
very badly at times. No one should have access to this 
but the nurse on that branch of the service. She makes 
the record of the patient, doctor, and ward on her spindle 


192 


THE OPERATING ROOM 


or wall-file till it is returned. If not in good condition, 
she reports to the hospital buyer, who charges it against 
the ward—“Retention catheter, No. 14 (mushroom), 
Ward B, Mrs. Amelie Mintz, Signed, Mary Jones, Ward B, 
charge nurse.” 

These catheters are washed in soap and cold water 
with care to remove the usual lubricant, then held under 
the cold faucet and milked, like a cow’s udder, to remove 
any solid particles, then boiled in old muslin, and hung to 
drain in a cool place. 

1. Stretch to see if resilient. 

2. Discard rough or cut, slashed catheters. 

3. Male catheters should not be kept in the same box 
as those for women. 

4. Orderlies may be sometimes entrusted with stock 
for the wards, but must not be allowed to come to the 
nurses in the operating room (if necessary, send ward 
nurse). 

5. To avoid many embarrassments, one great hospital 
supply firm makes female catheters only 8 inches long— 
it does not touch an unscrubbed part, nor twist aiid drop. 

6. All catheters should have funnel-shaped distal ends. 

(2) Mushroom and T-Retention .—These are retained in 

the bladder, and are inserted above, in the course of the 
operation, or at its conclusion, while the patient is yet 
relaxed, by means of an olive-pointed bougie or a large 
uterine probe. No force is employed, but a vast amount 
of lubricant. Very, very slender uterine dressing forceps 
may be used, but it is risky, on account of the numerous 
folds of mucous membrane in the urethra, and only when 
the patient is fully under the anesthetic. 

Filiforms.—These are kept in a cool place in a very 
long box, in lycopodium powder. Some are fine as horse¬ 
hair, some are olive tipped. They are used for delicate 
genito-urinary work, such as determining the patency of 
the male urethra in cases of stricture (diagnostic, like a 
ength being added to the surgeon’s finger) and also the 
latency of the fallopian tubes in cases of relative steriltiy 


FORMULAE AND DIRECTIONS 


193 


(caused by scarlet fever, etc.). They are washed in cold 
water and dilute tincture of green soap, then dried, and 
hung in the formaldehyd cabinet. 

Bougies. —After a stricture has been located, a passage 
may be created with mild pressure by a bougie, which is 
a solid, stiff catheter made of waxed silk or catgut, chem¬ 
ically treated to be firm. They are cleaned and disinfected 
as above. Mice must not be allowed to eat the shellac on 
bougies (thereby roughening the surface). 

Silk Catheters (Elastic Web).—These must not be bent 
or boiled. They are of woven silk, covered with shellac, 
and must be kept cool at all times. They are harmful to 
the delicate urethral canal, if roughened the slightest bit, 
by causing an abrasion, then a stricture. They must be 
washed in cold water and Castile or Ivory soap. All white 
soap ends should be boiled down into a jelly for these uses. 
Drain, then dry, and hang in the fumigating cabinet. 

Fumigating Cabinet. —The hospital carpenter can im¬ 
provise such a cabinet, covering its seams with “gum tite.” 
It can be carried with its door to a window to let off the 
fumes of the candles of formaldehyd last used. Fine 
cabinets of iron and glass are made for this by the hos¬ 
pital supply companies. 

Preservation of Specimens. —When a surgeon cuts a 
section out of a doubtful breast, gut, or cervix, to be 
“frozen” and examined immediately, before proceeding 
with the operation under one continuous anesthetic 
(amputation) a long journey to a distant laboratory is 
out of the question. Everything must be planned before¬ 
hand to be ready in the workroom: 

(1) Microscope placed advantageously as to light, 

on a solid table. 

(2) Stool. 

(3) A watery solution of formalin, 5 per cent., 

three to five minutes’ immersion. 

(4) Alcohol, 50 per cent., three minutes’ immersion. 

(5) Absolute alcohol, one minute. 

(6) Wash off with water, stain, etc. 

13 


194 


THE OPERATING ROOM 


This is a speedy “combination freezing and fixation” 
method by Dr. Thomas Cullen of the Johns Hopkins 
Hospital. It is the nurse’s duty to provide the stock 
materials and utensils, graduates of various sizes marked 
by the metric system, and to clear a place wide and light 
enough for the pathologist to work. 

Care of Glassware. —There are never enough connecting 
tubes. Glass catheters, medicine droppers, etc., are 
washed in soap and water, rinsed, boiled ten minutes and 
kept in bichlorid of mercury 1 : 1000, or formalin 2 per 
cent., or boric acid 4 per cent. The rubber tops of 
medicine droppers are a trap. They may contain pure 
lysol that could be squirted next into a baby’s eyes. They 
must be perfectly washed. 

Soda Bicarbonate Solution. —This is given in the 
operating room or with aseptic precautions at the bedside 
in cases of acidosis and diabetic coma, in two ways: 
Subcutaneously, 

Intravenously. 

A 3 per cent, solution (30 gm. in 1000 c.c.) is made, 
filtered, and boiled five minutes to sterilize, in a Florence 
flask stoppered with gauze and cotton. Solutions for 
immediate intravenous use need be boiled only once. 

Glucose Solution. —This is made from solid grape 
sugar. It is used in rectal feedings in strength from 5 to 
10 per cent. In subcutaneous and intravenous injection 
it is given in 5 per cent, solution only. Dissolve 50 gm. 
glucose in 1000 c.c. boiling distilled water. Filter and 
boil in a Florence flask five minutes. Stopper as above. 

Silver Leaf.— This is bought in books of paper leaves, 
interleaved with these delicate gossamer sheets (Fig. 22). 
Cut the book into sections of 5 sheets each. Protect 
each booklet by 2 sheets of heavy cardboard, wrapping it 
in a double muslin cover (pinned, point buried in muslin) 
and label. Sterilize one booklet only for twenty minutes 
at 15 pounds. Do not sterilize the remainder till about 
to be needed. They become too friable. Silver leaf is 
made with a hammer, beating out the actual metal into 


FORMULAE AND DIRECTIONS 


195 


an incredible thinness lighter than air. To keep unsterile 
goods in reserve saves money. A large sterilized bulk 
runs no danger of being infected. It is used over area 
denuded in skin-grafting. 

General Rule About Sterilizing .—All clean articles (such 
as silver leaf, never exposed to germs) which cannot be 
boiled and are not used again are sterilized at 15 pounds 
for twenty minutes. 

How to Prepare Sterile Adhesive. —Cut the strips the 
desired length and width. Roll on a wide-mouthed bottle 
in single thicknesses (gallon bottle). Sterilize in the 



Fig. 22.—Silver foil. 


dressing sterilizer in a double muslin cover. When 
needed, the bottle is set on the suture table and filled with 
hot sterile water, tempered at first with cool. 

Hooks and eyes as substitute for skin sutures. A 
certain successful surgeon uses adhesive edged with hooks 
and eyes to avoid the stitch abscess and yet obtain a 
fine line of union. 

Sew the hooks and eyes on two strips of white 1-inch 
tape at the exact proper distances, for a length of 8, 10, 
or 12 inches, to be slightly longer than the characteristic 
incision made by the surgeon. Cut sheets of adhesive 
the same length and 6 inches wide. Leave the crinoline 











196 


THE OPERATING ROOM 


on the adhesive except on the edge at the median line, 
where it is removed for the width of 1 inch. Plaster the 
tape down here, with the hooks and eyes on, slightly 
turning in the edge of the adhesive. Face the bare inch 
surfaces with adhesive, its edge also turned in a little. 
Overcast the edge down among the hooks and eyes. Then 
remove the crinoline, and plaster the two sheets side by side 
on a large (gallon) bottle. Put up in a double muslin 
cover, sterilize, and remove as above. 

Diachylon Plaster.—This has been used eighty years. 
It is made with a lead base. Heat it over an alcohol flame 
before applying, but do not burn the patient. The nurse 
should test it to her cheek. Used in orthopedic work. 

Syringes.—Nothing is more neglected than syringes 
(of all kinds). Nothing is more badly needed at the time, 
and the cost of goods destroyed is scandalously large. 
Syringes must be taken apart, and washed in cold water 
after oils, human or animal blood or serum, etc., with 
fine bristle brushes (such as for drinking tubes), then 
boiled separately, cooled, wet again, and put together. 
Care must be taken never to wet the wick at the head of 
the plunger with the drug or serum. 

Care of Tracheotomy Tubes in Situ.—This is begun 
before the patient comes off the table. The tube is best 
cleaned by pheasants’ feathers, which are flexible and 
pointed though firm. They should always be on hand. 

The whole apparatus is covered with gauze moistened in 
soda bicarbonate solution, because the mouth and throat 
secretions are usually acid. Inner tube must be in. 

Care of Instruments: 

I. The Cabinets.—Calcium chlorid on a saucer in the 
cabinets minimizes the humidity, for which there is a 
scale or dial with hand or indicator in the back wall. 
When it deliquesces, new dry lumps should be sub¬ 
stituted. 

Camphor placed similarly here and there preserves the 
luster of the instruments by preventing oxygenation. No 
rubber in cabinets. 


FORMULA AND DIRECTIONS 


197 


Instruments should be put away boiled free of all germs 
from last patients, though the cabinet is not “sterile,” 
and arranged according to: 

(1) Surgeon owner, 

(2) Rooms where used, 

(3) Operations required for, 

(4) Age, condition, size, state of repair. 

Knives should be in original boxes. 

Sounds are rolled separately in flannel (no contact 
with each other) or slipped into the compartments of a 
bag such as used for flat silver in a residence. Contact 
causes roughnesses, which cause abrasions, which cause 
strictures. 

Cabinets should stand in a corridor not in line with the 
sterilizing room, to avoid humidity. They should be in¬ 
spected weekly, and inventoried at set dates. 

H* ^ * * * 

II. Cleaning Instruments. —A. After operations account 
for all needles, knives, clamps, etc., and classify in dif¬ 
ferent basins. Take to hopper room. If one instrument 
is missing, get it immediately —even at the peril of re¬ 
opening the patient or taking an x-ray of him. 

B. Wash in cold water to remove blood or pus. Wear 
heavy gloves p. r. n. 

C. Prepare instruments for boiling as follows: 

1. Fasten the needles in thick gauze with two bites 
each, and cover. 

2. Fold the knives and scissors into old muslin, each in 
a layer by itself. 

3. Drop blunt instruments in, wrapped also in muslin. 

4. If house rules require, sterilize edged tools with 95 
per cent, carbolic acid and alcohol. 

5. Add a handful of sodium carbonate (washing soda), 
if the boiler is not aluminum, 

(а) To soften the water, 

(б) To prevent rust, 

(c) To raise the temperature, thus facilitate steril¬ 
ization. 


198 


THE OPERATING ROOM 


6. Do not let scum or crust become deposited on bare 
instruments. 

7. Boil for ten minutes after clean, twenty minutes 
after septic cases. 

D. Scouring. Carry from the hopper to the workroom 
after lifting out the tray. Drain, unwrap. Use a thick 
oak or pine knife board, 1J by 1 foot by 1 inch, with a 
headpiece to push against, a place for brushes and Bon 
Ami. 

Rub with 

Well-boiled flat wide corks, 

Pieces of gauze, 

Flannelette, 

Small coarse tooth brushes (5 cents) 
in order to get into the corrugations and crevices. 

An electric emery burr, such as one finds in well- 
regulated homes to clean the chasing on silver, is priceless 
for uneven instruments. It may be run by the same motor 
as the sewing-machine, as all this is done in the work¬ 
room. Emery is a very fine abrasive and leaves no 
scratches. 

E. Inspection. See if they need repair (new parts, sharp¬ 
ening, renickeling). If so, set aside at once. Do not let 
go into general circulation again. Drop into a wide flat 
basin with a lathery solution of tincture of green soap, 
then with hot water, then transfer to a basin of alcohol, 
there to w T ait to be all dried together. Set pan of dry 
instruments in a warm place. Keep a large stock of old 
soft, highly absorbent towels (preferably linen) for drying. 
A pint of alcohol may be used over and over for this 
purpose if filtered and then tightly corked and labeled 
for this use only. Oil the corrugations, locks and joints, 
as well as all screwed parts with Three-in-one before laying 
on the shelves. Needles are threaded with suitable silk 
and run in flannel. 

Hollow needles of 
Trocar, 

Spinal puncture, 


FORMULAE AND DIRECTIONS 


199 


Syringes, 

Aspirators 

may be dried by standing vertical on a metal sheet over 
a mild flame or radiator, or lying with stilet in, on same. 
Otherwise they may be held in forceps very high over an 
alcohol flame (dry without smoking). Oil stilet before 
inserting (dry). 

Never put away a needle or trocar without its stilet. 
Platinum needles are best. Always clean the stilet with 
abrasive and push it through needles loaded with best 
abrasive. 

Ivory-handled Eye Knives .—These must not be boiled. 
Wash, dry, and sterilize in formalin or benzine, rinse, and 
wipe dry (after operation). 

Any knife should be used only once, then sharpened. 
The delicate edge is not electronickel plated like the 
body of the blade. They should be washed and dried 
immediately after using, and laid in parallel rows, no two 
parts touching. 

Hospital Cold Cream. —For the anesthetic room some 
cream is needed for patients who fear the use of vaselin, 


etc.: 

White wax. 5 iv 

Spermaceti. ...... .. 5iv 

Liquid petroleum (white mineral oil). § xxxij 

Sodii borate (borax). § ss 

Rosewater.... 5xvj 


Melt the wax, spermaceti, and oil together at a very moderate 
heat. Dissolve the borax in the rosewater, then warm this solution 
and add it to the melted waxes and oil, and stir briskly until cool and 
creamy. 

Hospital Hand Lotion: 


Powdered tragacanth. 5j 

Alcohol. 5ss 


Mix together and quickly add 1 pint of water and stir briskly. 
Add 1 ounce of glycerin and 2 ounces of alcohol and add water to 
make 1 quart. 

Perfume to suit. 

To Sterilize Vaselin. —Sterile vaselin is prepared by 
setting the container in a water-bath and putting a 









200 


THE OPERATING ROOM 


dairy thermometer in the vaselin, raising it to 212° F., 
and keeping it at that point for an hour. The lid is boiled 
beside, but not on, the container. To obtain sterile vaselin 
from such a jar afterward dip in a sterile grooved direc¬ 
tor that has not been included on the instrument table. 
Do not put in the gloved finger. The grooved director 
may be then drawn over a sterile compress or applied to 
the glove. One can judge by the surface being intact 
that the vaselin is sterile. This should be done daily in 
cases of constant catheterization, etc. 


CHAPTER XI 


THE METRIC SYSTEM 

This is discussed in an elementary manner because 
many girls lack the mathematical sense. 

LINEAR MEASURE 

The basis of the metric system is the unit of length. 
From it are worked out all other measures: 

Square, or surface, second dimension, 

Cubic of solids, or volume, third dimension, 

Cubic, of liquids, or capacity, 

Cubic, of weight, of dry solids. 

Weight changes at different levels above the sea and in 
varying temperatures. 

Capacity changes are due to density at certain times or 
other physical conditions. 

In order to have an unvarying standard for distance, 
international and indisputable, the French, when changing 
their government and other systems, took as a unit that 
measure which is one ten-millionth of the distance be¬ 
tween the Equator and the North Pole, and called it a 
meter, which means measure (39.37 inches). 

In this one dimension, to get smaller units of length, 
always dividing by 10, they used Latin prefixes to denote 
diminution, and adopted this scheme uniformly through 
all their system of weights and measures. Whenever the 
prefixes 

deci, 1/10, 
centi, 1/100, 
milli, 1/1000, 

are used, the original quantity is diminished by so much, 
whether it be length, surface, volume, capacity, or weight. 

201 


202 


THE OPERATING ROOM 


For example: 

meter = 39.37 inches (or one yard plus 3 T 3 o 7 ff inches), 
deci-meter = 3.937 inches (or about £ foot), 
centi-meter = .3937 inches (about 2/5 inch), 
milh-meter = .03937 inch (about 1/25 inch). 

In this linear dimension, to get larger units, multiplying 
by 10, Greek prefixes were adopted, to denote increased 
length. 

For example: 

meter = 39.37 inches, 
deca-meter = 393.7 inches, 
hecto-meter = 3937.0 inches, 
kilo-meter = 39370.0 inches. 

(about f mile). 

The word kilometer became very familiar to American 
soldiers in France as the measure of distance on their 
marches. 

Possible Problems in Linear Measure: 

To rule a chart in columns each 3 decimeters wide: 

1 decimeter = 3 r 9 o inches (approx.). 

39 X 3 

3 decimeters = ——— = ll x 7 ¥ inches (12 approx.). 

The nurse should make actual drawings of these meas¬ 
urements, to be able to form a proportionate mental 
picture of any object described by the metric system. 

SQUARE MEASURE (OF SURFACES) 

Square measure is derived, too, from the meter as a 
unit of length, as we multiply length by length to get 
area. If a plot of ground is 5 meters long and 4 meters 
wide, it contains 5X4 meters = 20 square meters. 

This does not occur frequently in the American nurse’s 
work. However, a possible problem would be 

To cut compresses 10 centimeters square, i. e., 10 centi¬ 
meters long and 10 centimeters wide. 

If 1 centimeter = 2/5 inch (approx.) 

10 X 2 

then 10 centimeters = —-— = 4 inches (approx.)—the compresses 
would be 4 inches to each side = 16 square inches. 




THE METRIC SYSTEM 


203 


CUBIC MEASURE 

Cubic measure is used in wood, earth, sand, stone, con¬ 
crete, etc., as well as in water, saline, glucose solution, 
soda solution, sterile water, etc., in the operating room. 
The basic unit here is a cubic centimeter, which is ar¬ 
ranged by erecting a mass of any of the above substances, 
which is 1 centimeter long, 1 centimeter wide, and 1 
centimeter thick (or high). 

VOLUME 

Nurses are concerned mostly about volumes of water 
and saline. Their problem is to grasp the ratio between 
American quarts and metric cubic centimeters. A c.c., 
or cubic centimeter , is a volume of water which has the 
following proportions: 

length = 1 centimeter (about 2/5 inch). 

width = 1 centimeter (about 2/5 inch). 

thickness = 1 centimeter (about 2/5 inch). 

appearing to the eye as follows: 



and in American measurement contains 2/5 X 2/5 X 2/5 
= 8/125 cubic inch. 

The cubic centimeter is the unit for measuring sub¬ 
stances such as saline or sterile water. 

A volume of water 10 centimeters long, 10 centimeters 
wide, 10 centimeters high, or 1000 cubic centimeters, equals 
our American quart (approx.) and is called a liter in 
France. 

If 1 quart = 1000 c.c., 

then 1 pint = 500 c.c. 

Memorize this, but remember its significance. 

One pint fluid measure = 7680 minims. 

One c.c. = 1/500 of 7680 = 15 minims (approx.) fluid measure. 

Memorize. 





204 


THE OPERATING ROOM 


WEIGHT 

In order to have a unit of weight, the scientists then 
took as the base 1 c.c. of water again. But water varies 
as to 

Mineral content, 

Organic matter, 

Density, 

Temperature, 

reacting on each other, 

therefore they had to stipulate certain conditions about 
this basic unit: 

It must be distilled water (uniform the world over), 
at 4° Centigrade (when water is heaviest or 
densest). 

They called this unit one gram. It is the starting- 
point for all substances that are weighed, such as boracic 
acid crystals, bread, sugar, flour (in nephritic or other 
diets), salt, etc. 

Again, the Latin prefixes denote diminution: 

1 gram = 15 gr. Troy (dry weight). 

deci-gram = 1.5 gr. Troy (1| gr.) or one-tenth. 

centi-gram = .15 gr. Troy (3/20 gr.) or one-one-hundredth. 

milli-gram = .015 gr. Troy (3/200 gr.) or one-one-thousandth. 

Once more, the Greek prefixes denote multiplication: 

deca-gram = ten times one gram = 150 gr. Troy (5/16 oz.). 

hecto-gram = hundred times one gram = 1500 gr. Troy (3£ oz.). 

kilo-gram = thousand times one gram = 15,000 gr. Troy, about 
2 lbs. 

Kilogram is the unit by which meat, etc., is bought 
where the metric system prevails. 

It is not absolutely true of all drugs at all times, but 
approximately speaking, in order to get a good mental 
picture, it is safe to say that minims (wet) = grains 
(dry), that is, the units in fluid and Troy are equal. 

“A pint’s a pound, the world around.” 

A liter (1000 c.c.) = 2 pints. 

A kilogram (1000 gm.) = 2 pounds. 


THE METRIC SYSTEM 


205 


Many European countries and some institutions and 
professions here and there in America have adopted the 
metric system. It is especially suited to pathology, which 
has only recently attained its proper rank among the 
departments of medical science. 

CENTIGRADE THERMOMETERS 

It is necessary for every nurse to read the two kinds of 
Centigrade thermometers correctly (clinical and dairy) be¬ 
cause they are employed frequently by certain institutions 
or professions or nations. She must at the close of her 
term in the operating room be able to explain these data 
to another nurse correctly, and with force to hammer it in. 

The Fahrenheit thermometer was not consistently con¬ 
structed. On it the freezing-point of water is named 
32 degrees above zero. 

On the contrary, it was the most intelligent thing in 
the world to consider the freezing-point of water as zero, 
dead, nothingness, etc., which the Centigrade does. 
Both were purely arbitrary man-made apparatus, not a 
natural growth. Again, for the same reason that zero is 
too far down on the Fahrenheit scale, boiling-point was 
put too far up. The space between was divided into 
too many degrees, too near together, with too little per¬ 
ceptible difference between neighboring ones. Boiling- 
point (at sea level) was called 212°. Those who travel or 
study physics know that water boils faster on a mountain 
top because there is less air pressing down on it. Hence 
we standardize by measuring temperatures at the sea-level, 
which is uniform throughout the world. 

Centigrade thermometers designate boiling-point as 
100°, to be consistent with the metric system (and their 
own name). 

Note the following object lesson: 


206 


THE OPERATING ROOM 


A. Dairy. 

rr2l2°BOILING POINT 


IOO° BOILING POINT 


FAHRENHEIT 

DAIRY 

THERMOMETER 

-ioo° 


CENTIGRADE 

DAIRY 

THERMOMETER 


32°FREEZING POINT 

O ZERO OR 32° BILOW FREEZING POINT 


u-o ZERO OR FREEZING POINT 

Fig. 23. 


Nurse’s Problem .—To heat a douche to 40° C., having 
only a Fahrenheit thermometer to test the solution. 

The distance between boiling (212°) and freezing (32°) 
Fahrenheit is designated by 180° or divisions. 

The distance between boiling (100°) and freezing (0°) 
Centigrade is designated by 100° or divisions. 

.*. 100° C. = 180° F. 
and 1° C. = ttr F. 
and 40° C. = 40 times {U = 72° F. 


But this means 72° F. higher than freezing-point, or 72° 
above 32° = 104° F. 


B. Clinical. 



Fig. 24. 












THE METRIC SYSTEM 


207 


On the two clinical thermometers the scale registering 
body heat is only a small part of the total scale between 
boiling-point and freezing. 

One must always take into account the loss between 
freezing-point and zero (32°) on the Fahrenheit scale. 

A nurse would be quite startled to see that a patient 
was only 37°—till she had these two scales correlated. 

94° F. = 62° above freezing 

180 divisions of the Fahrenheit soale = 100 Centigrade 

1 = if 

62 = 62 X if = 35f° 

98 t 6 q° F. = 66 t 6 o° above freezing. 

66 t 6 o° F. = W X if = 37° 

110° F. = 78° above freezing. 

78 divisions F. = 78 X if = 43|°. 

The clinical centigrade thermometer is constructed to 
show whole exact degrees at the ends. 

Lastly .—How frightened should a nurse be at rise of 
temperature indicated on a Centigrade thermometer in 
a patient, a sterilizer, or a solution? Almost twice as scared 
for one degree C. as for one old F. degree. On the new 
thermometer with its condensed scaling, one degree of rise 
is bad in the inverse ratio to that of the old. There are 
only 100/180 as many divisions, hence each fluctuation of 
a degree C. is 180/100, or nearly twice as bad. 

Each nurse should draw these thermometers and dem¬ 
onstrate fluently before receiving her credentials for the 
service in the operating room. 


CHAPTER XII 


OPERATING-ROOM PHARMACOPOEIA 

U. S. P.—The Government protects its people by a 
strict standard in procuring and dispensing of drugs. 
The details are clearly and fully laid down in a book 
called the United States Pharmacopoeia (U. S. P.). New 
discoveries are made and thoroughly tested by severe 
critics before being admitted to the U. S. P. When a 
substance is listed there, it may be regarded as perfect 
for its purpose as therein described. Similarly, a drug 
listed elsewhere as B. P. means that it is satisfactory 
according to British standards. Climate, topography, 
humidity, exposure to air, light, heat, or cold (within 
buildings) all have effects on certain drugs. This must be 
learned and actively practised in order that the patient 
may receive 100 per cent, of benefit from the admin¬ 
istration. 

Preservation of Drugs.—1. Volatility. —Benzine, ether, 
ammonia, camphor, amyl nitrite, etc., must not be exposed 
to air. They deteriorate or disappear. Deterioration may 
mean simply 

Losing force, or 

Changing its chemical nature and becoming deadly. 

2. Exposure to Light .—Adrenalin chlorid is an example. 
It should be kept in dark brown bottles, with a paper 
wrapping. 

3. Heat .—Do not keep near a warm pipe, or a sunny 
window, or above a gas burner. 

4. Age .—Argyrol should not be used after one to two (?) 
days. 

5. Moisture. —Bromids, etc., deliquesce and cannot be 
measured. 

6. Exposure to Air .—Iodin is dissolved in alcohol, 
which evaporates every time the cork is removed, becoming 

208 


OPERATING-ROOM PHARMACOPOEIA 


209 


more dense, i. e., relatively stronger than the original 
tincture. Hence only very small bottles should be in 
regular daily use, or there will be burns. Collodion, 
being made with ether, becomes more dense by evapora¬ 
tion (may be corrected by adding ether). Iodin is put 
up by a foreign firm in small ampules covered with woven 
silk, to be broken as needed (excellent). 

Safeguarding Poisons. —Of this there are many ways, 
but it is humanly impossible to guarantee: (1) That the 
brain of the worker will always be alert; (2) that it has no 
blind-spot; (3) that the field is always covered by a 
succession of suitable persons. None of the following 
methods are perfect: 

A. Knuckles or hard-pointed prominences annealed on 
the outer surface of poison bottles. 

B. Pin transfixing the cork, to prick the fingers of 
somnambulists. 

C. Bell that jingles (also for somnambulists) at neck of 
the bottle. 

D. Skull and cross-bones grinning hideously on the label 
(no good in dark). 

E. Key to poison closet in responsible hands. 

The best way and the only safe way is not to have 
any on hand. But that is out of the question. The 
quantity and range of poisons in the operating room may 
easily be very limited. They can be had on short notice 
from the pharmacist. 

Safeguarding Valuable Drugs. —Alcohol is bought free 
of excise on a bond involving the personal honor of the 
Board of Directors. If a nurse stops to think of that, 
she should never use it for her own spirit-lamp, and she 
will prevent orderlies from taking it as a beverage. She is 
the stewardess for grave, responsible citizens who cannot 
be present, and do not doubt her willingness to mount 
guard for them. 

Safeguarding Narcotics. —The responsibility for tab¬ 
ulating and doling out narcotics must be deputed by the 
resident officials to some nurse. A superintendent cannot 
14 


210 


THE OPERATING ROOM 


have an interview or conference interrupted by pupils 
converging on him from all wards after a surgeon makes 
rounds and orders morphin. If a nurse has not had 
uprightness and stamina at eight years of age, to be 
custodian of certain property, she w T ill never have it. 
Hospitals never yet put honesty into anybody. Honesty 
should be one of the requirements on admission to the 
school, tested for during probation, and forever more. 
However, to keep the arithmetical account correct, it is 
better to make one person or one group responsible, for 
the cash value of the goods is very high. 

Moral Responsibility.—People of all ages answer “yes” 
to the question, “Am I my brother’s keeper?” The nurse 
learns to take up this burden when she watches over 
cocain or morphin, to prevent others from becoming drug 
addicts. She is not a useful member of the community 
till she assumes responsibility for the acts of those under 
her, preventing wrong, teaching right. 

Preservation of Asepsis.—(1) Drugs may be dry steril¬ 
ized (by counsel with pharmacist on effect of heat), wrapped 
in double muslin cover, and shaken over wound with 
aseptic precautions ( e . g., aristol). 

(2) Some drug solutions may be boiled to sterilize 
(see pharmacist)—not all. 

(3) Some drugs are powerful germicides themselves, 
but must be handled with aseptic precautions. (See 
chapter on Asepsis, i. e., iodin on umbilicus last, then thrown 
away.) Collodion spreader should not be used and re¬ 
turned to bottle. Keep spreader in ether—drop collodion 
on, then spread. Made of ether and gun-cotton—an ex¬ 
plosive; also inflammable. 

(4) Find out at what stage aseptic precautions may 
cease. 

(5) Keep printed codes of rules on boiling, heating, or 
steaming drugs and solutions. 

Methods of Computing Cocain Solutions.—Quick meth¬ 
ods of calculation are not reliable, because, with the 
average young woman’s dislike of mathematics, and the 


OPERATING-ROOM PHARMACOPOEIA 


211 


strain of operating-room emergencies, the result is mental 
paralysis. 

There must be a sound reasoning process developed, 
and each problem must be worked out on paper and sub¬ 
mitted for the examination of a supervisor (old rule of 
three). 

Stock may be 

A. Tablets. 

B. Solution (do not let cloud). 

A. Tablets , gr. \. —Problem: 3j of 4 per cent, solution 
(to remove small cyst, etc.). (See Chapter XI on Formulae 
and Directions.) Grains v to 3 j = a 1 per cent, solution. 

I. If a 1 per cent, solution = 5 gr. to 5j, 

Then 4 per cent, solution =4X5 = 20 gr. to Bi¬ 

ll. If in 5 j of a 4 per cent, solution there are 20 gr., 

Then in 5j there are | of 20 = 2 \ gr. 

III. If in 1 grain there are 6 sixths (as per stock), 

Then in 2 \ gr. there are X 6 = 15 sixths. 

Take 15 tablets from stock for 1 dram of sterile water. 
(The addition of adrenalin counteracts depression and 
enhances local vasocpnstriction.) 

B. Solution , 20 per cent. Strength. —Problem: Make 3j 
of 4 per cent, solution. 

Amount required = 5 j or 60 minims. 

Stock solution 20/4 or 5 times as strong as solution required, 
.•.strong stock dose must be only 1/5 of total amount prepared. 
1/5 of 60 = 12 minims. 

Take 12 minims of stock solution + 48 minims sterile water. 

Method of Computing Hypodermic Dosage.—A is the 

most difficult problem ever given any nurse in this divi¬ 
sion. Use the old-fashioned Rule of Three. 

Example A: 

Stock tablets nitroglycerin gr. 1/100. Dose ordered, gr. 1/16. 
How give it exactly? 

Ratio of gr. 1/100 to gr. 1/16 is as 16 to 100, 4 to 25, which is less 
than 1/6 and more than 1/7. 

therefore gr. 1/16 contains not quite 7 and more than 6 times gr. 

1 / 100 . 

therefore dissolve 7 tablets marked gr. 1/100 and take proper 
proportion of solution, thus: ... .. . • 


212 


THE OPERATING ROOM 


7 tablets should be dissolved in some number of minims that is a 
multiple of 7. , 

It must not be too large or too small to inject into the arm, as 28 
minims. . . ... 

If 7 tablets or 7 times 1/100 gr., or 7/100 gr. = 28 minims (dis¬ 
solved in) 

then 1/100 gr. = 4 minims solution 

and gr. 1, or 100/100 gr. = 100 X 4 = 400 minims 

and gr. 1/16 = 1/16 of 400 = 25 minims. 28 — 25 = 3. 

Expel the air and 3 minims. Administer 25 minims. 

Example B: 

Stock tablets, morphin, gr. Dose ordered, gr. |. 

Which is the stronger? gr. £. 

The number of minims in which to dissolve the tablet must be 
approximately right for injection into the subcutaneous tissues. 

It must also be a multiple of 8, the denominator of the dose 
required. 

Multiples of 8 are 16 and 24—24 is too large for hypo, injection- 
take 16 minims of sterile water to dissolve gr. £. 

If gr. £ = 16 minims, 

Then gr. 1, or 6/6 = 6 X 16 =96 minims. 

and gr. | = £ of 96 or 12 minims of that solution. 16 — 12 = 4. 

Expel 4 minims and give 12 m. 

Example C: 

Stock tablets, morphin, gr. |. Dose required, gr. f. 

Which is the stronger? gr. Then take two-eighths of a grain, 
dissolve in some suitable multiple of the denominator of the dose 
required—6, 12, or 18. Choose 18, as it will be reduced, and dis¬ 
solve two eighths. 

If gr. | be dissolved in 18 minims sterile water, 

Then gr. | equals \ of 18 =9 minims, 
and gr. | (or gr. 1) equals 8 X 9 = 72 minims, 
and gr. | taken, equals \ of 72 = 12 minims 
IS - 12 = 6. 

Expel 6 minims and give 12 m. 

Legal Phases.—Nurses should not dispense, measure, 
or weigh out powders, etc., not being licensed phar¬ 
macists. Small hospitals should protect their patients 
and their own reputation by keeping within the law. 
An institution receiving public funds should retain an 
attorney to advise on these knotty points, where copy¬ 
rights, inland revenue, or the restrictions imposed by the 
law to protect certain professions which are ethical, and 
to protect the people from quacks and untrained prac¬ 
titioners, are concerned. 


CHAPTER XIII 


DRESSINGS 

General Principles. —Simplicity must be the keynote- 
To introduce fads is to shackle the workers and imperil the 
patient. Print the rules for cutting and putting up on 
heavy cardboard. Limit the styles and number of sizes 
of sponges as far as consistent with the best results for 
the greatest number of patients. Pupils should take 
permanent notes of measurements, etc. Houseclean 
methods once a year. Exercise economy. Each institu¬ 
tion should record its standard measurements and num¬ 
bers in packages. 

Gauze. —(A) Sponges— See Fig. 25. Usually three 
simple styles are enough for the biggest hospitals and 
the most famous surgeons. 

1. Probangs, or small sponges for long sponge sticks. 

2. Flat gauze or folded compresses. 

3. Tape sponges (laparotomy) or long rolls uncut. 

The probang may be made slightly larger for tonsil 

work, the area being more vascular, with fewer chances to 
suture or ligate. Demonstration needed. Flat gauze 
must be cut to measure, and all loose edges turned in. 
The marvelous precision of the trained Red Cross work¬ 
ers in making dressings could put to shame many nurses. 
The patients do very well now with a light abdominal 
dressing, such as a few compresses. 

Tape sponges are cut to measure, made by hand, and 
heavy metal rings caught on tape to prevent loss in the 
abdomen. 

Dr. H. S. Crossen of St. Louis describes in the Journal 
of the American Medical Association, vol. 81, No. 19, 
November 10, 1923, his method of sponging from one 
long sterile roll in a pocket on a towel over the patient’s 
side, absolutely eliminating all need of sponge count. 

213 


214 


THE OPERATING ROOM 




Fig. 25.—-Use of the gauze strip sponge: Ready to sponge with the 
end of the strip. (H. S. Crossen in Jour. Amer. Med. Assoc.) 


Fig. 26.—Use of the gauze strip sponge: The soiled portion gravitates 
out of the field. (H. S. Crossen in Jour. Amer. Med. Assoc.) 

To safeguard the patient from infection, hemorrhage, 
and hernia his wound is covered next with two or three 















DKESSINGS 


215 


thicknesses of wide iodoform packing, then he is sheathed 
heavily in enormous quantities of adhesive. If he is not 
special ed continuously, he may sit up or get out of bed. 

B. Mastoid Tips .—It is most gratifying to be able to 
hand the proper style of dressing to a surgeon who has 
not previously visited the hospital. Operations relating 
to-the special senses (eye, ear, nose) are entitled to some 
special dressings. Mastoid tips are arrow-shaped sponges, 
whose point enters small pus pockets in the cells of the 
mastoid bone. 

Cut the yard wide folds of gauze into 16 squares, 4 to 
a side, twenty layers. Lay one pile flat. Pull a piece off 
with the left hand. Catch it by the right forefinger and 
thumb in the very center, and, closing the left hand, pull 
it through. Lay this “arrow” to the right side, with the 
nose pointing away and the tail nearer. After about a 
thousand are made, pick them up with the right hand, 
place the noses in an even row or cluster, turn and trim 
off the ragged ends with one “snip” of large bandage 
scissors, leaving the “tips” 6 inches long. Put up in 
bundles of 30, in double muslin, evenly laid. 

C. Mastoid Dressing .—Arrange for sterilization in the 
double muslin squares as follows: 

1. A square of blue tissue to keep cotton fluff off the 
cover. 

2. A square of best absorbent cotton 6 inches each 
side (for an adult), then blue tissue, then another square 
of cotton. 

3. A piece of plain gauze packing, 9 inches long and 
\ inch wide. 

4. A gauze roller bandage, best quality, 2 inches wide, 
which sets well when it is moistened on account of the 
sizing in it. 

D. Gant Pad .—Used for hemorrhoidectomy or pro¬ 
lapsed rectum. Make the usual flat folded compresses, 
each one-quarter of the large gauze square yard. With 
all the raw edges turned in, these are 4| inches square, as 
measured up to the patterns cut, or lined in the surface 


216 


THE OPERATING ROOM 


of the work-table. Take two compresses and cut each in 
half. Turning in that raw edge, fold the first half-piece 
in four equal layers, the second in five, the third in six. 
Roll the fourth in a tight, hard roll, keeping tight tem¬ 
porarily with a safety-pin in the center. Lay them in a 
pyramid, the widest at the bottom, to make a wedge. 
Take two strips of adhesive, each 6 inches long and 
^ inch wide, and wind the ends together tightly. This 
causes the wide bottom layer to lie flat, and each one above 
it to bulge more and more. When the convex side is laid 
against the anus, the whole being pressed home with a 
very tight perineal binder the convexity is increased. 
When well lubricated, it forms a good dressing for a pro¬ 
lapsed rectum or bleeding hemorrhoids, being secured by 
stout adhesive straps from buttock to buttock. 

E. “Whistle” or Tampon Cannula .—This prevents oozing 
of blood after hemorrhoidectomy by exercising pressure 
in the rectum (or anal canal). 

The advantages are: 

(1) Blood can show in the outer dressings. 

(2) Flatus may escape painlessly to the patient. 

(3) Enemata may be introduced. 

A piece of stiff rubber tubing 3 inches long is sterilized, 
smeared with sterile vaselin, and wrapped around with 
plain gauze, vaselin being rubbed in at every turn of the 
cloth. Wind the gauze spirally at what will be the entering 
or proximal end, so that it presents the form of a truncated 
cone. Slip a large safety-pin through the distal end, so 
that it may not entirely disappear into the rectum. 
Finish with split gauze compress pad and a T-binder. 

F. “Canule a Chemise” (Petticoated Tube). —(1) Gauze 
is gathered about the end of a piece of rubber tubing, just 
like the cloth of an umbrella at the ferrule of an umbrella s 
hanging down loosely from it like the unbound umbrella. 
(2) Or a sponge may be rolled over a medium-sized tube 
(or rubber-dam over gauze), the ends are secured with ties 
of catgut, and lubricated well with boric acid ointment. 
The tight end is inserted in the rectum, the loose part 


DRESSINGS 


217 


acting as a drain and a fluffy pressure pad, all being well 
smeared with vaselin. 

G. Leg Rolls. —The selvage must be cut off everything, 
always, to produce a softly yielding spiral when applied. 
Cut off three thicknesses of the yard-square gauze in 
one piece, folding over so that the selvages come to¬ 
gether. Then pare them off very sparingly. Then cut in 
two, down the center fold, making thus two pieces, J yard 
wide and 3 yards long. Open out, turn in the ends about 
2 inches, fold long edges almost to the center, and fold 
over, making a strip 4§ inches wide. Hold squarely on 
the solid work table and roll very evenly. Put up in 
packages of two. 

H. Stump Dressing. —Six strips laid in the form of a 
Maltese cross. 

I. Eye Pads. —(1) To prevent ether eyes, cut a piece 
of gauze 8 inches square. Fold it on itself laterally. 
Leaving a space of \ inch in the center, bounded by 
vertical stitching, pad it to fill in the hollows of the eyes 
and nose, so that when it is laid on the face, random drops 
will not pass through. (2) Others take 20 thicknesses of 
gauze, 14 x 20 inches, and bind with l-inch tape, and 
quilt on the machine. Hole in the center to fit the nose,, 
in half the number of pads made, not in the others. Put 
up one of each, in cover. Sterilize. When opened, the 
notched one goes next the face, the square one above. 

J. Fornices of the vagina are best packed by plain 
sponges, in a hurry, in postpartum hemorrhage. But if 
the doctor desires a strip, hand him a small strip for the 
uterus and heavy for external—no threads. 

K. Bandages. —Every nurse should be an expert ban- 
dager, so that the doctors would leave that to her. Espe¬ 
cially she should be able to apply a bandage with the edge • 
turned in, and deftly catch it with needle and thread to 
stay in position. 

L. Packing. —Use the best of gauze in sheets, with 
threads drawn—strips cut—folded, or the best of gauze 
bandages with the sizing washed out. If not, it is very 


218 


THE OPERATING ROOM 


painful to remove (being set with blood and sizing). Label 
packing according to its complete width when opened. 
Sit with right foot on a low stool. Turn in the end of the 
strip, then turn each edge to center. Then fold the two 
halves together, which makes the final strip only one- 
quarter the open width. Roll the first few inches with 
both hands into a tape-like roll. Then pin securely as 
much as is finished. Then, holding the raw bandage or 
strip, in the left, and the finished roll in the right, turn 
the edges in to the center, and again, with a sawing motion 
over the knee, aided by the fingers of the left and applying 
traction with the right. Pin securely every few inches, 
after rolling up steadily with the right. Use the same 
only two pins, and do not lose them. They alternate like 
cribbage pegs. 

Use a pin point packer (Dr. Dench’s packer for lifting 
up grafts of skin from the spatula) to plait packing into 
tubes. 

Tubes should be open at both ends to permit passage, 
from end to end, of live'steam. Plug at both ends with 
cotton and put up in double muslin covers, labeled out¬ 
side, according to width when single. 

. M. Retractors .—Long strips of gauze are used, held by 
a nurse, in ear work. 

Cotton.—A. Cotton balls must be made of the finest 
grade of absorbent cotton, on account of the extreme 
delicacy of the field where they are used—the eye. It 
is not good to use cotton in other fields because it leaves 
threads internally that become a foreign body. 

B. Aristol Pledgets .—For ear work. Take a very thin 
shred of the finest absorbent cotton, and pick it, till a 
circle | inch in diameter remains, then gather all the 
shreds into it toward the center, and lay it on a glass slab, 
rolling it with the tips of the second and third fingers, 
back of the hand horizontal as at the piano. With prac¬ 
tice, these may be rolled into perfect balls, like the “pills” 
of the opium addict. When a large number of these are 
made, of assorted sizes, they are then stirred about in a 


DRESSINGS 


219 


square glass basin containing about 5ij of aristol, till they 
carry all they can. They are then sterilized in jars. 

C. Applicators (Long) for the Ear. —The soiled piece on 
any applicator must always be pushed off by a piece of 
clean cotton. The knack is to wind it tight enough to 
operate and loose enough to remove. Demonstration is 
required. Take a thin shred of cotton about 1 inch square, 
of even thinness. Lay the tip of a 6-inch double wooden 
ear applicator in the center. Roll the cotton trumpet 
shaped, fastening it by indentation with the thumb-nail 
at the base. Wind both ends—place in glass tubes 
open at both ends—put up in double muslin and sterilize. 

D. Toothpicks (Short Applicators) for the Eye. —Choose 
toothpicks of pine or cedar, rather rough, cut square, 
and bellied in the center—not the fashionable (?) rounded 
cafe toothpick, Too highly polished to catch and hold the 
cotton. Pick into a thin square a wisp of absorbent cotton, 
best quality—fold into a triangle, like a diaper—lay the 
end of the toothpick (first weak half-inch broken off, 
lest it break in operation) in the middle of it, and roll, 
finishing by indenting with thumb-nail at the base. Then 
to make it smooth and pretty revolve it with the right 
hand, holding the cotton cone between the tips of left 
thumb and second finger, beveling it into shape with the 
tip of the forefinger. These are discarded after using. 
If inserted into an infant’s nostrils, the cotton must not 
come off nor the end break. 

E. Applicators All Cotton. —For babies’ noses a long, 
stiff, slender rod of rolled cotton is most safe, as it cannot 
break nor abrade. 

Tampons.—Required—lambs’ wool, or best grade ab¬ 
sorbent cotton, smooth stout cotton cord (knitting cotton 
No. 4) or heavy white linen thread, and the medications 
required. Cut in squares 4J inches to the side. Roll 
fairly snug. Throw a double line, by its folded end, twice 
around the waist of the roll. Pass the free ends through 
the noose and work tight, then steep in the medication 
required. 


220 


THE OPERATING ROOM 


For a very young patient at the first examination 
tampons may be made in small clusters, like balls orna¬ 
menting articles of worsted, as small as a cherry. 

Cotton 1 inch square and \ inch thick—wind with noose 
at center—spread the ends of the cotton to meet over the 
cord and trim till round and even. Then the number 
needed can be gaged to the cavity. 

Boroglycerite must be set on a plate and the bottle 
washed after using, as it escapes in large quantities. 

Linen Bobbinette.—This is used for 
Tying umbilical cord, 

Cigarette drains, 

Scalp wounds—drain, 

Rubber tubing with iodoform. 

Muslin Bandages.—Tear off selvages and ravel smooth. 
Use factory cotton (unbleached muslin) of good quality. 
Cut into 5-yard lengths. Cut each end into the desired 
widths, with little snips for markers. A piece 36 inches 
wide, minus selvages, should make 17 2-inch bandages, 
allowing for ravelings. Two nurses collect the loose tabs, 
Miss A taking 1, 3, 5, 7, etc., Miss B taking the alternate 
2, 4, 6, 8, etc., firmly in both hands, and, walking away 
from each other 2J yards, they tear all the strips at once. 
Wind on bandage roller, split the end, tie one knot, and 
tie around. 

Flannelette bandages the same. Never cut hand-made 
bandages off a patient. Unwind and wash. 

Wick should be kept in small quantities for drains, 
syringes, etc. 

Chiropodists’ Plaster.—A neat way to finish bandages 
on fingers or toes is to secure with chiropodists’ plaster 
from spools. Neck bandages are wide and may be tied, by 
leaving the first end loose and one foot long, to be caught 
when done, in with the last. Tying is more comfortable 
for the patient. Adhesive should not be used near hair, 
nor pins near the eyes or blood-vessels. 

Cloth Retractors.—These are intended to hold the soft 
parts out of the way during an amputation, while the 


DRESSINGS 


221 


bone is actually sawed. A.piece of stout unbleached 
muslin, 2 feet long and 1 foot wide, is torn lengthwise 
half-way, into two or three tails, put up in double muslin 
cover, and sterilized. Two tails are needed for the hu¬ 
merus or femur, three tails (leaving the middle narrow 
tail for the interosseous space) in the forearm or leg, be¬ 
cause these have two bones. (Gauze bandages used like¬ 
wise in small radical ear operations.) 

Tape Stickers.—These should be made to suit various 
sizes of abdomen and wound, considering also the danger 
of hernia from obesity or distention. Use the best quality 
of adhesiye, no matter whether it is on spools or rolls, 
though that by the roll seems economical in cutting the 
widths. 

For solidity in handling use a piece of basswood splint 
as a back, 9 inches long and 3 inches wide. Nick the 
end of the sheet of plaster in 2-inch or 3-inch widths (p. 
r. n.) ready to tear, and tear the required length, cutting 
them off below. Carefully remove the crinolin, part of 
which is to be used again. At one end fold down one 
corner squarely on itself a little beyond the center (about 
If inches), then the other, uniformly on top of it, making 
an even folded point. This overlapping past the center 
gives three thicknesses to hold the tape. Now fold this 
point on itself and make a V-shaped nick all the way 
through. Then lay the strip on the basswood, gummy side 
to, so that the ends are flush, and it adheres for 4 inches. 
Fold back on itself, and apply the crinolin to the re¬ 
maining space as far as the folded tip. Take now 9-inch 
lengths of J-inch white tape, make a nick 1 inch from the 
end, running lengthwise with the tape. Slip the short end 
through the hole in the adhesive, then thread its long end 
through its own eye. Make six to a splint. 

T-Binders.—These may be made up in the linen room, 
well stitched to endure a long time, but frequently they 
are hard to find. One can make a T-binder quickly from 
a muslin bandage, as follows: For a woman patient of 
medium height and girth take for waistband 36 inches of 


222 


THE OPERATING ROOM 


a 3-inch muslin bandage. Fold it in the center crosswise, 
and slit it for b inch, the cut running lengthwise with the 
bandage. Take for the perineal strap a second piece, 
24 inches long, and fold it lengthwise, 3 inches from the 
end, slitting it crosswise for 1 inch. Thread this short 
bit through the hole in the waistband, then thread the 
long end of the 24-inch strip through its own eye. For a 
male patient split the perineal strap for the last 18 inches, 
to secure the dressings at the groin. This strap saves 
safety-pins. 

Ether Cones.—The ether cone made with several folds 
of newspaper and a small towel, pinned and stuffed with 
gauze, is the most satisfactory yet. Actual demonstration 
is required for its peculiar knack. 

Making of Supplies.—This must be supervised by the 
operating-room head nurse. The surgeons should take 
counsel as to who shall make dressings: (1) Probationers; 
(2) operating-room pupils; (3) convalescent clean patients; 
(4) Junior Auxiliarjr; (5) Red Cross; (6) church groups; 
(7) friendly special nurses. The effectiveness of the 
sterilizers should be beyond a doubt, then in times of 
stress outside help of this sort, under hygienic condi¬ 
tions, could probably be safely utilized. If the dressings 
are not made in the operating room, at least the suture 
nurse should learn how to take charge of the work. Dis¬ 
tinction may be made between ward dressings and operat¬ 
ing-room supplies. 


CHAPTER XIV 


LINEN OF THE OPERATING ROOM 

Estimation of Stock Required.—Quite careful study is 
needed to estimate properly the quantity of linen needed 
for an operating-room. A chart similar to that appended 
(p. 224) may be compiled. 

Whiteness of Linen.—This is determined by 

(a) The method of washing, 

( b ) Where dried, 

(c) How stains are prevented, 

(d) How stains are taken out, 

(e) The nature of the goods, 

(/) The chemicals in the water-supply, 

( : g ) Special goods for isolation, 

(h) Improper sterilization-—burning, not steaming. 

(а) Washing white goods: 

(1) Nurse sends down, ready—put linen in cold water 
in machines. 

(2) Rinse cold twenty minutes. 

(3) Warm water and soap twenty minutes—wash by 
machinery. 

(4) Warm rinse ten minutes—very important. 

(5) Hot water and soap twenty minutes—wash by 
machinery. 

(б) Hot rinse five minutes—very important. 

(7) Hot rinse five minutes. 

(8) Hot water and 4 ounces of acetic acid to the ma¬ 
chine, for ten minutes. 

(9) Cold water, add the blue, ten minutes. 

Wyandotte soda precipitates lime salts (with chipped 

soap). Buy by the barrel. Anilin blue (No. 90) in 
1-pound cans is purchased for the coloring. ( b ) The water 
should be analyzed. See that the servants do not buy 

223 


224 


THE OPERATING ROOM 


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LINEN OF THE OPERATING ROOM 


225 


sulphuric acid themselves for quick bleaching. It has 
been known to occur. Drying in the open air is the best 
way. If not possible, certain articles at least may be 
held back, and dried and wet again repeatedly till white. 
To have a large number of articles and bleach with sun¬ 
light is more economical than to have a few and let them 
be eaten by chemicals. Do not buy advertised “aids” 
till they are analyzed, (c) Nurses should be taught to 
handle linen without letting it get stained. For iodin, 
argyrol, bichlorid of mercury, etc., only old mended 
articles should be used. ( d ) A code of formulae should 
be framed in the hopper room, giving the suitable instruc¬ 
tion for every sort of stain that may occur. Nothing 
that rusts should be washed with the linen. ( e ) Some 
twilled goods are naturally dough colored. Linen, on the 
contrary, takes a beautiful white. (/) Rivers into which 
waste is poured from factories are a bad source of water- 
supply. 

(g) Rust on white goods may be removed by 

(1) Cream of tartar paste + sunshine—or 

(2) Lemon juice and salt, or 

(3) Rust soap. 

Grease (vaselin, etc.) disappears on application of 
ether, but this is costly. 

Bichlorid of mercury makes a gray stain, removed by 
Javelle water, or Labarraque’s solution, diluted 1 :6. 
Formulae for Labarraque’s: Sodium carbonate 10 parts; 
chlorid of lime, 8 parts; water, 100 parts. 

(h) Do not send good material to isolation for two 
reasons: It takes a long time to get back, and by some 
mischance it might not be disinfected, so, coming to the 
common center, redistribute contagion through the hos¬ 
pital. Use large old linen ends for contagion or dirty 
staining dressings. 

Training Economics.—A priceless part of a nurse’s 
training is that under a competent housekeeper on the 
points of contact with the other phases of domestic 
science. It looks as if at some time nursing might be 

15 


226 


THE OPERATING ROOM 


made one of the branches of that bigger field. She may 
learn how to arrange the work for others, to buy goods, to 
provide materials, and to co-ordinate the efforts of all on 
whom she must depend for her own success. To be com¬ 
prehending, systematic, economical are most essential in 
one who wishes to hold office worthily anywhere. 

Measures.—The book of measures shall contain the 
quality, price, addresses of manufacturing firms, sizes, 
and patterns of all the garments mentioned following. 
The pupils should learn these details to see their success¬ 
ful application, so as to build up similar, and, it is 
always hoped in one’s pupils, better systems when they 
hold office. 

Here should be a carefully made card of samples kept 
shrunken and unshrunken, with this book, showing the 
smoothness, number of threads to the inch, etc., to 
train in good buying. Goods should be bought about 
twice a year to save time and expenses in freight, and 
to train in forethought. The use of a good thread gage 
is taught. 

Nurses’ Gowns.—Nurses should have well-fitting gowns. 
They vary more in stature than men do, and the distance 
of a gown from the floor is more vital to a woman. A 
sloppy gown cannot be aseptic. It should be ironed. 

Doctors’ Gowns.—Usually these look uncomfortable. 
A square yoke shrinks, and if rough-dried, is smaller still, 
therefore hangs too far forward in the front, and hunched 
up behind. A round yoke is better looking. The goods 
should be shrunken before making, or ordered a size 
larger. The unshapely gown often seen cramps the arms. 
All should be ironed. Hospital outfitters usually make 
good gowns without yokes and inexpensively. 

Doctors’ Suits.—No man wishes to wear trousers made 
by a Women’s Auxiliary. The great garment-making 
houses make these suits at such a low figure, due to 
organization, that volunteer workers cannot rationally 
compete. The suit should be of soft material, being worn 
over the underwear and under the gown. 


LINEN OF THE OPERATING ROOM 


227 


Shields.—Muslin (bleached) is used for the shields in 
front of a students’ or visitors’ stand. 

Covers.—The instrument table which swings directly 
over the laparotomy sheet is best covered with a bag, 
made like a pillow case, the under side being as dangerous 
as the top. 

Masks, Helmets, Mouth-pads.—Masks for the suture 
nurse resemble a helmet, coming well below the neck band 



Fig. 27.—Suture nurse’s mask, New York Post-Graduate Hospital. 

of the gown (see Fig. 27), with an opening only for the 
eyes. For the attending surgeon, who will lecture in his 
clinic, the opening is larger. For the intern a small square 
of a few thicknesses of gauze, with four tapes to the back 
of the head, is considered enough, as he is a resident, and 
not out in the streets or crowds previously, or in the 
homes of infectious cases. 



228 


THE OPERATING ROOM 


Suspensories.—These should be kept in stock in the 
operating room. If not, they can be made from a couple 
of yards of 4-inch muslin bandage and applied with a 
few safety-pins by the orderly. 

Laparotomy Suits.—These are made of thick, fine 
Canton flannel, open at the back, with tapes only. The 
stockings should always go with them in sets. Each set 
should be folded to show its stencil— 


X. Hospital. 

Lap. suit. 

Length, 54 inches. 


This length (neck to heel) helps the nurse select for 
her patient. The only safe place to keep these usually is 
in the operating-room linen closet. The suit should be 
changed, after the surgeon closes the wound, for a dry set, 
warming in the blanket warmer. 

Scultetus Binders.—Nothing but Canton flannel of 
best grade will do for these. Remove the selvages. The 
measure of a binder for a patient is as follows: (1) The 
tails must each be four-fifths of the patient’s girth or 
once the patient’s girth, less the width of the back piece. 
(2) The back piece should be one-fifth the patient’s girth, 
and reach from the bulge of the thighs to the breasts. 
One most annoying feature of the surgical service is the 
dearth of well-made, well-ironed, large enough Scultetus 
binders, due to perspiration, accidents, and delay in 
laundering till a number accumulate. Many patients 
wear them home, due to carelessness of the ward nurse, 
or the patient’s dishonesty or ignorance. These binders, 
if made by the nurses in classes, will not be cut or lost so 
often as the pupils will realize how costly they are. There 
are two rules in applying this binder: 

(а) For obstetric cases, braid from the top down. 

(б) For surgical cases, braid from the bottom up. 

There are ten tails, cut, not torn, overcast finely by 

hand on all edges, not hemmed. 



LINEN OF THE OPERATING ROOM 


229 



The back piece is made from double its size, allowing 
for the making, the fold being at the hips, as in all binders, 
so that the patient does not lie on a seam. Baste first 
throughout. 

The tails are set in securely J inch, for firmness when 
braiding. 


Fig. 28.—Binder for breast amputations—sleeve spread to show 
pattern. 

Each tail should overlap the next for three-fourths of 
its width. They must overlap in the same direction on 
both right and left sides of the back piece. 

Allowance must be made for the thickness of a dressing 
when selecting. 

Goods must be shrunken before making up. 


230 


THE OPERATING ROOM 


Maternity Breast-binder with Sleeve.—This makes an 
ideal support for the dressings in a breast amputation 
(see Figs. 28 and 29) by adding a plain sleeve, ordinary 
style, men’s coat-sleeve, of double unbleached muslin. 
Open the sleeve on the outer surface, in a line running 
from the ring finger to the tip of the acromion process. 



Fig. 29.—Binder for breast amputations—sleeve folded. 


Close this, when the dressings are on and the binder 
applied, with four pairs of tapes (8 inches long). It cor¬ 
responds with the opening of the breast-binder at the 
shoulder, whose flaps extend about 1 inch past the sleeve 
on each side. The binder may be used for either breast, 
being reversible. The sleeve ends above the elbow./ 


LINEN OF THE OPERATING ROOM 


231 


Caps.—Outside of the amphitheater nurses should 
wear, anywhere else in the suite, caps that cover the hair 
completely. A very thin material, slightly starched, will 
do. It need not fit down on the top of the head too 
closely, but the style must be uniform for the service. 
On leaving the suite for other parts of the building, the 
school cap is put on. 

Laparotomy Sheets.—The opening should be not more 
than 10 inches long by 6 inches wide, making at any 
moment about a 16-inch ellipse, e. g., in cesarean section. 
The sheet should be wide enough to cover a very large 
abdomen and fall 6 inches below the edge of the table. 
For length, it must reach from the neck to the heels 
(including the length of the foot) plus 6 inches, but may 
be extended by placing another smaller sheet over the 
knees. Assorted sizes must be kept and marked. For 
babies a small slit in a large towel is good. 

Vaginal Sheets.—As shown in Fig. 30, a large number 
of sheets are required, that minimize the sense of exposure. 
They are easily put on over the sterile triangles which 
cover the stirrups. This sheet is so securely fastened that 
it makes above the abdomen a sterile table for the instru¬ 
ments. It is much more comfortable and economical than 
towels clamped in position. The set consists of 

2 triangles so folded as to make 2 halves of a square. 

1 vaginal sheet. 

In 1 muslin cover (if not loose in drums). 

A triangle is an unbleached muslin cone to cover foot, 
leg, and thigh. 

Gown Covers.—For reserve gowns, outside the drums, 
covers should be made (Fig. 31, a) like a pocket book, into 
which they are slipped, and secured with dome fasteners, 
saving time and vexation. These are particularly nice 
for a private physician’s kit. Glove envelopes are made 
also like a pocket book (Fig. 31, c, d). 

Covers for Packing Tubes.—Make a long, double 
tubular bag (Fig. 31, b) with a drawstring at the neck, 
put the tube in, fold over the loose end, to close, and tie 


232 


THE OPERATING ROOM 



Fig. 30.—Vaginal sheet. 

of stout unbleached muslin, stitched smoothly, with the 
name stenciled carefully outside. These covers are used 
for reserve stock or for ward use. 

Blankets.—The top blankets for stretchers should be 
of some dark color, preferably crimson, to be gay, and not 


tightly. Allow three per tube in stock daily needed. One 
is on the tube, one being laundered, one in reserve. Wash¬ 
ing prolongs the life of this stock. 

Dressing Covers.—The process of sterilization has been 
proved futile inside a thin cover. Covers must be double, 




LINEN OF THE OPERATING ROOM 


233 


show stains. They should be of pure wool, of generous 



length, from the crown of the head to the sole of the foot 
and over. They may be extended by a second blanket 


Fig. 31.—Some special covers: (a) Gown cover; (6) cover for packing tube; (c) glove case; ( d ) glove 

envelope. 





234 


THE OPERATING ROOM 


from the knees down. Heavy cotton blankets are worse 
than useless. They are to be kept clean, so as to remain 
unspoiled by washing. Towels may be folded over them 
at the chin. The supervisor must sign slips when blank¬ 
ets are sent to the laundry, and if one comes to the head 
of the laundry without a requisition, it should be held up*. 

Flannel Masks.^-These are made by hand, washed with 
green wool soap and rinsed in warm water, to which a few 



Fig. 32.—Gown and towel plaited in one direction—opening too 
easily with one movement. 


drops of glycerin are added. Stretch well, and dry for a 
time outdoors. 

Folding Linen.—There are two methods of folding 
linen. By one the article is taken at its full length and 
folded often enough to be a convenient width—a. towel 
once, a gown twice—then simply plaited, so that it may 
drop to its full length by only gently lifting one edge 




LINEN OF THE OPERATING ROOM 


235 


(Fig. 32). When a doctor is putting on a gown it is pre¬ 
sented to him with the collar uppermost. He takes it by 
the collar in a clear space in the room, and as he raises it 
it drops its full length. But the trouble with this method 
also arises from that very feature. Things opening too 
easily might be easily contaminated. The one counter¬ 
balances the other. The second method is to fold the 
article from its ends toward its center so as to control it 
perfectly. 

To fold a towel 24 by 30 inches or of similar proportions, 
lay k-o over on a-e, pressing the fold f-j firmly. Bring 


9 

h 

i 


l 

m 

n 

o 


Fig. 33. 


the double edges a-k to / and e-o to j to the center c-m to 
h, almost, but not quite, to prevent a hump. Now fold 
from b-l to g and d-n to i to the center again. Then fold 
together. In opening this towel hold the folds at d and at b 
in the right and left hands respectively, between the fore¬ 
finger and second finger. Hold the points at a and e 
between forefinger and thumb also. Keep the two 
thumbs close together and the whole towel compressed 
until, having wedged a way between two assistants, one 
has space close beside the area to open the towel out sud- 







236 


THE OPERATING ROOM 


denly like a fan and lay it in situ. This method keeps the 
whole bottom edge, h-l-m-n-o , securely fastened be¬ 
tween the thumbs until needed (Fig. 33). 

In folding gowns, hold by the under arm seams and let 
drop longitudinally into four thicknesses. The nurse 
keeps the under arm sides next to her and makes them the 
straight edge. The sleeves are turned (together) at a 
sharp right angle to this line, straight across the gown, and 
when they reach the opposite edge sharply folded back on 
themselves, perfectly flat and square. Do not bring the 
sleeves down along the body of the gown. Turn in tapes 
into the inner part of the openings on the farther edge. 
Fold from the collar and the bottom in almost to the cen¬ 
ter. By leaving 1 inch in the middle the folds lie flatter. 
By applying great firmness and long, steady strokes even 
linen that is rough dried may be made quite beautiful. 
A nurse’s hands ought to be as good as a mangle. All 
these articles should be laundry mangled, but binders are 
ironed. However, the laundresses do not fold for the 
sterilizing. The method of folding should be uniform 
throughout the hospital. If large sheets and blankets 
are folded in and in, they present a handsome appearance, 
since it hides any dissimilarity in stripes, while things of 
varying sizes that have to be used for the same purpose 
can be approximated to look the same, but laparotomy 
sheets and gowns must be folded in their assorted sizes 
to be selected quickly. 

There should be a large stock of bags in the workroom 
for dressings, both sterile and unsterile, ward, reserve, 
and operating-room supplies. These may be of stout 
unbleached muslin, carefully stenciled and very fre¬ 
quently laundered. 


CHAPTER XV 


TERMS USED IN SURGICAL DIAGNOSIS 

Reasons Why Nurses Should Know the Diagnosis.—(1) 

If the mistress in a small thorough-going menage prepares 
her own meals, she can be splendidly helped by an in¬ 
telligent maid if she states her menus twenty-four hours 
in advance. Similarly, though on a different plane, if a 
surgeon states that he will operate for cholecystitis, the 
nurse will be able to assist him very much better than if 
he just says “laparotomy,” because her class instruction 
with her supervisor enlightens her as to the nature, size, 
and number of instruments required, owing to the number 
of “layers,” dressings, etc. 

(2) In the routine work of the operating room the 
circulating nurse signs a slip for the enlightenment of the 
ward nurses, showing diagnosis, operation, stimulation, 
etc. She must therefore be able to grasp the terms when 
given and to spell them, i. e., to have a working knowledge 
of them. 

(3) The hospital takes care of the present and of the 
future of its patients, but the operating-room pupil loses 
the past , or history, entirely, and thus is not equipped as 
well as she ought to be to cope with those conditions 
found in the home, before diagnosis is made, where 
nine-tenths of all sickness occurs. Hence it is a most 
important duty of the supervisor to sketch the condi¬ 
tions preceding the operation, to associate them with the 
particular diagnosis in question. This must be done 
hastily, and is a very slim weak link with the nurse’s 
after life as a private special, where her observation of 
symptoms should be of such untold value to a cautious 
surgeon. 

Pathologic tissue means diseased tissue, in this in¬ 
stance to be treated surgically. It may be diseased by in- 
237 


238 


THE OPERATING ROOM 


flammation, benign or malignant tumors, cysts of a watery 
or purulent nature, malformations, transformations, con¬ 
genital absences of parts and other deformities, besides 
those resulting from accidents and wounds. All terms 
ending in itis denote inflammation of the part named, as 
cholecystitis, inflammation of the gall-bladder. 

TABLE OF TUMORS 


Normal tissue. Tumors found therein. 

Fibrillar connective tissue.Fibroma singular, 

fibromata plural. 
Greek nouns ending 
in oma form plural 
by adding ta. 

Mucous tissue.Myoma. 

Embryonic connective tissue.Sarcoma. 

Endothelial tissue.Endothelioma. 

Fat tissue.Lipoma. 

Cartilage..Chondroma. 

Bone. . . ..Osteoma. 

Neuroglia.Glioma. 

Muscle tissue type.Myoma. 

Smooth muscle tissue.Leiomyoma. 

Striated muscle tissue.Rhabdomyoma. 

Nerve tissue.Neuroma. 

Vascular tissue (veins and arteries).Angioma. 

Lymph vessels.Lymphangioma. 

Glands.Adenoma. 

Various forms of epithelial cells and associated 
tissues.Carcinoma. 


Compiled from standard works 

CYSTS 

Cysts are sacs filled with watery, purulent, or cheesy 
material, and are of two kinds: (I) Those developed from 
pre-existing cavities. (II) Those originating independ¬ 
ently after pathologic changes. 

Class I is formed by an accumulation in a gland or its 
excretory ducts of secretion (altered somewhat) when 
pressure or inflammation hinders normal discharges. 
This secretion is either mucous, sebaceous, or serous. 
To these belong the comedone, milium, ranula, chalazion, 
atheroma, milk cyst, ovarian cyst, cysts of fallopian 
tubes, of gall-ducts, the transudation cysts due to chronic 


















TERMS USED IN SURGICAL DIAGNOSIS 


239 


inflammation in the lymph-spaces or serous sacs—namely, 
ganglia, hydrocele, and hematocele. 

Class II is formed (1) by the softening and disintegra¬ 
tion of tissue (e. g., from old abscesses); (2) or by the for¬ 
mation of a wall around foreign bodies (parasites, masses of 
blood producing an inflammation and becoming encapsu¬ 
lated); (3) or by new growths in whose spaces various 
kinds of fluid accumulate, quite like glands, as adenomata 
on the ovaries, though they are called cystomata; (4) or 
congenital cysts, dermoid cysts of the ovary or of sub¬ 
cutaneous tissue (as the scalp), being probably part of 
another fetus. 


GLOSSARY OF TERMS 
A 

Abortion. Expulsion of the contents of the pregnant 
uterus before the child is viable (end of sixth month). 

(1) Abdominal. Escape of fertilized ovum into per¬ 
itoneal cavity, where it attaches itself to the intestine. 

(2) Complete. The sac comes away intact. 

(3) Criminal. Procured artificially without being 
necessary from the legal standpoint of the patient’s 
health. 

(4) Epidemic. Arising from the presence of conta¬ 
gious disease. 

(5) Habitual. Repeated, due to syphilis usually. 

• (6) Incomplete. When the membrane or placenta is 

retained. 

(7) Inevitable. When the sac has ruptured and the 
fetus is about to appear. 

(8) Septic. When the patient becomes infected 
through the introduction of bacteria or the decay of re¬ 
tained tissue. 

(9) Spontaneous. Not induced by artificial means. 

(10) Therapeutic. Induced to save the mother’s life. 

(11) Threatened. Appearance of symptoms which are 
checked by putting the patient to bed and giving her 


240 


THE OPERATING ROOM 


opiates. This usually can check an honest miscarriage in 
the early symptoms. 

Abscess. A localized collection of pus surrounded by 
a wall of leukocytes. 

Cold Abscess. Tuberculous, usually about a bone, 
joint, or gland—slight pain, no acute inflammation, very 
slow. 

Psoas Abscess. Both cold and psoas are misnomers, 
generally low Pott’s disease; pus from the spine runs along 
the psoas muscle pointing beneath Poupart’s ligament. 
The psoas muscle runs from the lumbar vertebrae to the 
lesser trochanter of the femur. Poupart’s ligament runs 
from the anterior superior spinous process of the ilium to 
the symphysis. 

Adenoids. Hypertrophied tissue in nasopharynx. Note 
the spelling of pharynx (y = i, rynx = rinks. Pronounce 
farinks). 

Adenoma. May become malignant, as sarcoma; many 
are benign, but some are most malignant—an epithelial 
tumor. 

Amenorrhea. Abnormal absence of menstruation. 

Aneurysm. A circumscribed dilation of the walls of 
an artery. 

Angioma. A tumor formed of blood-vessels—benign. 

Anomaly. An abnormal thing or occurrence, a marked 
departure from the normal. 

Anteflexion. A bending forward or doubling on itself 
forward. 

Antrum. A cavity or hollow space in a bone, as in 
the mastoid, often infected; antrum of Highmore in the 
superior maxillary. 

Appendicostomy. Opening the vermiform appendix at 
the tip and irrigating the colon downward for the purpose 
of eliminating the germs which make that their abode. 

Appendix (Vermiform). Small blind gut hanging from 
the cecum. 

Ascites. Obstruction of portal circulation in chronic 
heart and kidney diseases causing a collection of fluid in 


TERMS USED IN SURGICAL DIAGNOSIS 


241 


the peritoneal cavity. To let off this transudate we “tap” 
or do a “paracentesis” with a trocar, which passes through 
without infecting the peritoneum, with aseptic precau¬ 
tions. 

Asphyxia. Suffocation: lungs deprived of oxygen. 

Atheroma. A sebaceous cyst containing cheesy mate¬ 
rial. 

Atresia. Lack of normal opening, e. g., to the vagina. 

Atrophy. Diminution in the size of a tissue, organ, or 
part. 

Atypic. Not resembling its type; irregular, freakish. 

B 

Bartholin’s glands. Vulvovaginal glands whose tiny 
openings appear about at the center of the inner surface 
of the labia minora, a seat of venereal infection. 

Benign, Benignant. Not endangering health or life. 

Bile-duct. The haunt of the Bacillus coli communis, 
the typhoid germ, etc. 

Boil. A furuncle; a localized inflammation of the skin 
and subcutaneous tissues, with formation of pus. 

Bone-grafting. A new field in surgery, dating from 
about 1911, where a healthy bone is planted to splint and 
support or take the place of an unhealthy one, the callus 
thrown out by the irritated bone forming union, e. g., 
the tibia to the spine. 

Bubo. Suppurative inflammation of a lymph-node, 
usually in the groin and usually venereal. 

C 

Cachexia. Depraved condition of general nutrition 
due to syphilis, tuberculosis, or carcinoma; weak, tough, 
yellow, muddy skin, and emaciation. 

Calculus. Stones in the ureter, kidney, gall-duct, or 
bladder, sometimes causing occlusion of- the ureters and 
consisting of uric acid, oxalate of lime, phosphates or 
cystin— a stone-like concretion inciting pyelonephritis— 
when in the gall-ducts, of bile pigment. See Gall-stones. 

16 


242 


THE OPERATING ROOM 


Capsule. A receptacle or bag; covering of certain 
organs, e. g., the kidney, the liver, some cysts, and parts 
of the eye. 

Carbuncle. Hard, circumscribed, deep-seated, painful, 
suppurative inflammation of subcutaneous tissue, larger 
than a boil, with a flat top and several points of suppura¬ 
tion. 

Carcinoma. Malignant epithelial tumor prone to local 
extension through the lymph-spaces. It may appear at 
any age and may have inflammation, ulceration, and 
hemorrhage. It is more frequently found in some parts 
of the world than in others. The age limit is said to be 
lower now only because patients are handing themselves up 
sooner to physicians and the complex life of this time 
ages people faster. Epithelioma occurs in skin where 
it joins the mucous membrane on the lips, eyelids, labia, 
mouth, esophagus, vagina, or cervix. It may not recur 
if thoroughly removed, and is the least malignant of the 
carcinomata. Cylindric-celled carcinoma occurs in the 
stomach, intestine, and uterus. Carcinoma simplex 
occurs in the mammae, stomach, liver, thyroid, salivary 
and prostate glands, in the pancreas, testicle, ovary, 
and kidney. Some of these are the most malignant. 
There has been no serum or toxin yet discovered as a 
cure, but early recognition and early radical operation 
save many lives. 

Caries. Death of bone; similar to ulceration of soft 
tissues. 

Caruncle. Small, fleshy growth, frequent in women,, 
in the meatus urinarius. 

Chalazion. A tumor of the eyelid from retained secre¬ 
tion of the meibomian glands. 

Cholecystitis. Inflammation of the gall-bladder. 

Cholelithiasis. Presence of stones in the gall-bladder 
or gall-duct composed of bile-pigment, that is, choles- 
terin and certain salts. By lying together they become 
faceted, and may exist in as large numbers as 7800. 

Cholesteatoma. Cells packed with cheesy matter, 


TERMS USED IN SURGICAL DIAGNOSIS 


243 


benign tumors in the dura behind the ear; found in 
mastoid operations. 

Chondroma. Benign tumor of the covering of carti¬ 
lage, but it may extend into the lungs or heart. 

Cicatrix. A scar; connective tissue replacing a local 
loss of substance, the new being red or purple, the old 
white, hard, shriveled, and shiny. 

Circumcision. Removal of foreskin or prepuce for 
cleanliness and prevention of self-abuse. 

Cirrhosis. Chronic inflammation of an organ and-over¬ 
growth of connective tissue. 

Clitoris. A very small organ in the female in front of 
the pubic joint, somewhat resembling the penis in the 
male, and extirpated to check self-abuse. 

Colic. Appendiceal. Pain and rigidity of spasms due 
to inflammation. 

Biliary. Passage of gall-stones through the gall-duct 
into the duodenum. 

Intestinal. Severe griping pain in the bowels due to 

Renal. Pain caused by stone in the ureter, 
spasm of the intestinal walls. 

Comedo (sing.), Comedones (pi.). Disorder of the se¬ 
baceous glands; in the young, yellowish elevations with 
black points in the center associated with acne. 

Condyloma. A wart-like growth or tumor near the anus. 

Congenital. —Existing at and since birth. 

Convergent. Coming together, as in squint. 

Cornu (sing.), Cornua —horns (ph). The projecting 
upper corners of the uterus into which open the fal¬ 
lopian tubes. 

Culdesac of Douglas. A pouch between the front 
wall of the rectum and the back wall of the uterus made 
by the peritoneum. 

Curetage. Curetment—scraping out the uterus. It 
is essential for the honor of the hospital to have a true 
history. 

Cyst. A cavity containing fluid and surrounded by a 
capsule. 


244 


THE OPERATING ROOM 


Cystocele. Hernia of the bladder. The back wall of 
the bladder drops down, pushing out the front wall of the 
vagina, the weight of urine increases this, and finally may 
pull down the cervix and the uterus. 

D 

Decapsulation. Taking off the capsule of a diseased 
organ to establish new circulation and reduce inflamma¬ 
tion, as of the kidney, for nephritis or bichlorid poisoning. 

Dermoid cyst. A sac containing hair, teeth, nails, 
and other forms of epithelial tissue. 

Detritus. Waste matter from disorganization. 

Dilation. As correct as dilatation —act of stretching. 

Distal. Farther away from the point mentioned. 

Divergent. Going apart, as in squint. 

Diverticulum (of bladder or esophagus). A pouch or 
sac springing from a weakness in the wall of a main 
structure, causing the contents to stop there which should 
pass on; symptom of diverticulum of esophagus in an 
adult, regurgitation of food just as sweet as when swal¬ 
lowed. 

Dorsum. The back of the hand, foot, tongue, etc. 

Dura Mater. Membrane covering the concave surface 
of the skull, “exposed” in ear operations under strict 
aseptic precautions, “going in” from outside, or the outer¬ 
most of the three coverings of the brain. 

Dysmenorrhea. Painful menstruation. 

E 

Ecchymosis. Large diffuse accumulation of blood in 
the interstices of the tissues. 

Ectropion. A disease of the eyelid turning it inside out. 

Effusion. A pouring out of blood or serum into serous 
cavities (pleura, peritoneum, pericardium). 

Embolism. Blocking of a blood-vessel, especially an 
artery, by foreign matter. 

Embryonic. Pertaining to the embryo, or fertilized 
ovum of an animal. 


TERMS USED IN SURGICAL DIAGNOSIS 


245 


Encapsulated. Surrounded by a capsule, as a bullet 
or any other foreign body. 

Endometritis. Inflammation of the lining of the uterus, 
with swelling, congestion, and even hemorrhages. 

Endothelioma. A sarcoma in the lymphatics. 

Endothelium. Lining of blood- and lymph-vessels and 
of serous and synovial cavities. 

Entropion. A disease of the eyelid turning it outside 
in, so that the lashes constantly scratch the eyeball. 

Epididymitis. (Note spelling.) Inflammation of epi¬ 
didymis, small organ lying above the testes. 

Epispadias. Opening of urethra, not at the end, but 
on the upper side of the penis, due to arrested develop¬ 
ment. 

Epithelioma. Carcinoma of the skin and mucous mem¬ 
branes. 

Exostosis. Bony tumor; an abnormal projection of 
bone. 

Extra-uterine pregnancy. Gestation outside the uterus, 
in the tube, fimbriae, peritoneum, or on the intestines. 

Extravasation. Passing of fluid outside of a cavity 
in which it normally ought to stay (of blood or lymph). 

Exudate. The material that has passed through the 
walls of vessels into the adjacent tissues (said of serum or 
pus). 

F 

Fascia. The areolar tissue forming layers beneath the 
skin or between muscles. 

Felon. Inflammation of flexor tendons and tendinous 
sheaths of the finger. See Paronychia, Whitlow. 

Fenestrated. Having a window or opening, as in a 
rubber drainage-tube, a pair of obstetric forceps, or a 
plaster cast over a sinus. 

Fibrin. Coagulating material in blood; small bunches 
of twigs are used to whip clots to separate the fibrin in 
looking for fetal or placental tissue. 

Fibroma. A tumor, benign at first, in skin and sub- 


246 


THE OPERATING ROOM 


cutaneous tissue may become serious through pressure, 
ulceration, etc. 

Fissure. A groove or cleft (normal) in the skull, 
brain, liver, cord, etc.; an abnormal fissure occurs at the 
junction of skin and mucous membrane, as the lips or the 
anus. 

Fistula (sing.), Fistulae (pi.), Fistulous (adj.). A narrow, 
winding, irregular canal in the soft tissues left by in¬ 
complete healing of an abscess or wound with fluid con¬ 
tents; must be entirely laid open and the edges beveled 
off so as not to approach again (usually rectal). 

Flap. A piece of soft tissue cut on three sides of a 
square and laid back to cover a scar, or to bring forward 
after an amputation to cover a bone end. 

Floating. Free to move around; abnormal, as a kid¬ 
ney, which has no ligaments at all to hold it up, merely 
fat. 

Fossa. A depression or pit. 

Frenum. A rib or fold of skin or mucous membrane 
that limits the movement of any organ. Under a new¬ 
born infant’s tongue an abnormal frenum should be 
promptly snipped or it cannot nurse and will be tongue- 
tied. 

Frontal sinus. Hollow air-spaces in the frontal bone; 
a seat of infection that becomes fatal at times through 
the easy way of reaching the brain; operated through the 
nose. 

Furuncle. A boil. 

Furunculosis. The constant formation of a succession 
of boils. 

G 

Gangrene. Death of a considerable mass of tissue. 
When it is mummified, dry and hard, brown or black 
it is classified as dry gangrene; when discolored and 
putrefying,, moist gangrene. It proceeds from wounds, 
diabetes, and other causes. It is not a cause for panic 
now, as formerly, in hospital wards. 


TERMS USED IN SURGICAL DIAGNOSIS 


247 


Glaucoma. Disease of the eye, with heightened ten¬ 
sion, hardness of globe, lessening of visual power, restric¬ 
tion in field of vision, dreadful headache, etc.; relieved by 
• iridectomy. 

Glioma. Tumor of neuroglia cells in the brain, cord, 
retina, nerves, and suprarenals; benign. 

Granulations. Formation of new vascular but nerve¬ 
less tissue in repair of wounds. 

Gumma. Third stage of syphilis in the brain. Should 
take precautions against contagion. It is a tumor with a 
gummy appearance, consisting of granulations and show¬ 
ing peculiar degeneration. 


H 

Hematocele. Blood extravasated into a closed cavity. 

Hematoma. Collection of blood in a tumor-like mass 
on a newborn infant’s “caput,” be it the head or but¬ 
tocks. 

Hemophilia. All words with the prefix hem (for blood) 
as their root should be spelled hem uniformly. Hemor¬ 
rhagic diathesis, condition of being a bleeder. Important 
question to ask in taking a history. When circumcising a 
newborn infant he proved a bleeder, and after all other 
means failed, a large number of the tiniest clamps ever 
made, covering the whole wound, saved his life. 

Hermaphrodite. A human being whose organs are so 
malformed as to partake of the nature of both sexes. 

Hydatid Mole (hydatidiform). Hypertrophy of the 
villi of the chorion, beginning as a fibrous mole; then its 
mucous membrane degenerates, then a hydatid mole. 

Hydrocele. Accumulation of fluid (serous) in the 
tunica vaginalis about the testicle or the spermatic cord. 

Hydrocephalus (the noun, note ending us). A head 
containing a collection of fluid in the cerebral ventricles, 
with steady increase in size. 

Hydrosalpinx. Fallopian tube dilated with water into 
the shape of a cyst. 


248 


THE OPERATING ROOM 


Hymen. A fold of mucous membrane partially closing 
the virginal vaginal opening. 

Hypospadias. The male urethral opening into a cleft 
on the under side (arrested development). 

Hypostasis. The settling of blood in the dependent 
or low-lying parts of the body. 

I 

Ileus (volvulus). A twisting of the bowel so as to ob¬ 
struct the passage of air, feces, or fluid; usually fatal. 

Impaction. A mass of fecal matter or calculi solidly 
packed; stones in the cystic duct cause dilation of the 
gall-bladder; very large stones sometimes cause occlu¬ 
sion of the gut. 

Imperforate. Without a normal opening, as of the 
anus (a hole from the rectum often leads to the vagina 
instead). 

Incarcerated. Walled in and bound around, as a hernia 
in a sac. 

Infarction. A circumscribed portion of tissue com¬ 
pletely infiltrated with blood. 

Infiltration. The entrance into the tissues (1) of some 
abnormal substance or (2) of some normal substance 
(as blood) in too great a quantity. 

Inflammation. Heat, swelling, redness, pain, and im¬ 
pairment of function; a rush of leukocytes to fight the 
invasion of bacteria. 

In situ. In the natural position. 

In statu quo. In the natural condition. 

Intercostal spaces. The muscular areas between the 
ribs, numbered. 

Intussusception. Slipping of one part of the intestine 
into the part beyond; telescoping of the bowel on itself, 
as the ileum into the colon. 

Invagination. Act of insheathing or being run into a 
sheath, as inverting the raw end of the appendix stump 
inside itself. 


TERMS USED IN SURGICAL DIAGNOSIS 


249 


K 

Keloid. An overgrowth of tissue standing out like a 
very full frill, usually in any old scar, and very common 
in the negro race. 

Kidneys. Subject to inflammation, have no support¬ 
ing ligaments, malformations quite common, as two in one 
or one missing, or one with two ureters, have tumors of 
various kinds; the healthy one should not be removed by 
mistake, this being the result of carelessness in marking 
specimens obtained after catheterizing the ureters. 

L 

Laceration. A tear, especially of the cervix or per¬ 
ineum in childbirth; repair is imperative. 

Lamina. Plates or layers applied to vertebrae. 

Laminectomy. Removal of the posterior arches of the 
vertebrae. 

Lateral. Belonging to the side; in a sideways direc¬ 
tion. 

Leiomyoma. Benign tumor of involuntary muscle. 

Lesion. An injury, a wound, or any diseased morbid 
condition in an organ. 

Leukocytes. White corpuscles. 

Leukorrhea. Whitish mucopurulent discharge from the 
female genital canal. 

Lipoma. Benign, fatty tumor. 

Lobe. A rounded part of an organ, separated from 
the others by fissures or clefts. 

Longitudinal. Lengthwise; in the longest direction of 
the body. 

Lymphangioma. Benign, but may rupture; a tumor 
made of lymphatic vessels. 

M 

Malformation. An abnormal development or forma¬ 
tion of a part of the body. 

Malignant. Applied to tumors; harmful, fatal. Known 
if (1) they spread by metastases; (2) they invade adja- 


250 


THE OPERATING ROOM 


cent material by eccentric or peripheral growth; (3) they 
tend to recur; (4) they interfere with the nutrition and 
general well-being of the body, inducing cachexia. 

Malposition. An abnormal position of any part or 
organ. 

Mastitis. In infants streptococcic or staphylococcic 
infection. Use no pressure, no massage. Inflammation of 
the breasts found in nursing mothers. 

Mastoiditis. Inflammation of mastoid cells behind the 
ear. 

Do not confuse these two terms. 

Median line. A line in the center of the body from the 
umbilicus to the symphysis pubis; imaginary. 

Menorrhagia. Excessive menstrual flow. 

Metastasis (sing.), Metastases (pi.). Transfer of dis¬ 
eased particles by the blood or lymph from the primary 
bed to a distant one. 

Metrorrhagia. Uterine hemorrhage; not connected 
with the menses or childbirth. 

Microcephalon. An abnormally small head. 

Milium. Small, pearly, non-inflammatory elevations 
on the skin due to plugging of sebaceous glands. 

Mole. Birthmark; a pigmented nevus. 

Mouse-tooth. Forceps with sharp teeth like a mouse’s. 
Do not be guilty of saying “mouth-tooth.” 

Multilocular. Having many cysts or “eyes”— middle 
(i l ) put in for ease in pronouncing. 

Multiple. Affecting many parts at the same time. 

Myoma. Benign muscular tumor, frequent in the 
uterus. 

Myxoma. A benign growth in connective tissue, but 
may recur; containing mucin , like Wharton’s jelly in the 
umbilical cord. 


N 

Naevus or Nevus. Vascular birthmark; “strawberry 
mark”; an angioma full of blood-vessels, benign and con¬ 
genital, corrected by skin-grafting. 


TERMS USED IN SURGICAL DIAGNOSIS 


251 


Necrosis. Death of a limited portion of tissue due to 
insufficient nutrition by (1) cutting off the blood-supply; 
(2) bacteria; (3) mechanical injury. 

Neuroglia. Has its origin in nervous tissue, but takes 
on the duties of connective tissue. 

Neuroma. Benign tumor; new formed nerve tissue. 

Node. A knob, swelling, or protuberance; the normal 
shape of many lymph-vessels. 

Nodule. A little node. 

Noma. Not surgical. An ulcer in the cheek rapidly 
spreading down the alimentary canal. 

O 

Obliteration. Removal or disappearance of a part. 

Obstruction. Blocking of the blood or the bowel. 

Occlusion. Closing or blocking off, as of the fallopian 
tubes, inducing sterility; or of the gall-duct with gall¬ 
stones. 

(Edema or Edema. Infiltration of serum into a part. 

Omentum. Useful for absorption and its fat supply; 
a fold of peritoneum hanging down like an apron in front 
of the intestines. 

Oophoritis. Note spelling, marking, and pronuncia¬ 
tion, not like oo in foot, but like oa in oasis. An inflam¬ 
mation of the ovary after the puerperium, or it may be a 
primary affection. 

Orchitis. Inflammation of the testicle. 

Organized clot. Found in curetings; blood converted 
into something looking like an organ or other living 
tissue. When curetings are examined they should be 
whipped with a bunch of twigs to separate the fibrin so 
as not to miss a tiny fetus. 

Osteitis or Ostitis. Inflammation of bone. 

Osteoclast. An instrument for breaking bones (bow¬ 
legs). 

Osteoma. When alone, benign; new formed bones 
found in the soft parts, such as the pleura or the dia¬ 
phragm, but often combined with sarcoma. 


252 


THE OPERATING ROOM 


Osteomalacia. A disease mostly of pregnant women; 
by the loss of inorganic salts bone which was hard and 
fully formed becomes softened and twisted, sometimes 
necessitating cesarean section. 

Osteomyelitis. Inflammation of the marrow of bone. 

Osteoplasty. Operation for bow-legs or knock-knees, 
for the cosmetic effect. 

Osteosarcoma. A sarcoma containing bone. 

Otitis Media. Inflammation of the middle ear. Diag¬ 
nostic : 

0. m. c. a. Otitis media catarrhalis acuta. 

0. m. c. c. Otitis media chronica catarrhalis. 

0. m. p. a. Otitis media purulens acuta. 

0. m. p. c. Otitis media purulens chronica. 

Ovary Transplantation. Taking a healthy ovary from 
one woman and sewing it into place in the body of an¬ 
other woman (1) to correct sterility; (2) to keep the val¬ 
uable ovarian secretions acting to prevent neurasthenia 
or masculinity. 

P 

Papillomata. Warty growths, fibromata of the skin: a 
papillary outgrowth covered with epithelium. 

Paracentesis. Puncture into a body cavity (ear, ab¬ 
domen, bladder, thorax, cornea); a “paracentesis knife” 
for ear work has a very small two-edged blade, so small 
that it can pass through a small ear speculum. 

Parenchyma. The essential or working part of an or¬ 
gan (e. g., the kidney); the body without the covering. 

Paresis. Some, but not complete, loss of muscular 
power (intestinal). 

Paronychia. An inflammation of the flexor tendons and 
tendinous sheaths of the fingers. (See Felon , Whitlow.) 

Patent. Open or exposed, as a valve. 

Patulous. Expanded or open. 

Pedicle. The stem or stalk of a tumor or cyst. 

Pediculated Cyst. Growing from the broad ligament 
and having a pedicle. 

Perichondrium. The fibrous coat of cartilage. 


TERMS USED IN SURGICAL DIAGNOSIS 


253 


Perineum. The floor of the pelvis from pubes to 
coccyx (adj., perineal). 

Peritoneum. Serous sac lining the whole abdominal 
cavity and containing the viscera (adj., peritoneal). 

Peroneal. Pertaining to the fibula or small bone of 
the leg. 

Do no confuse these three terms. 

Periosteum. Fibrous covering of bone—not to be 
destroyed. 

Periostitis or Periosteitis. Inflammation of the perios¬ 
teum. 

Petechiae. Very minute hemorrhages into the skin; 
sometimes seen in the newborn and others (adj., petechial). 

Phagedena. A rapidly spreading destructive ulcer of 
the soft parts. 

Phlegmon. Inflammation with spreading of purulent 
exudate within the tissues. 

Pia Mater. Membrane covering the convex surface of 
the brain, the middle one of the three meninges. 

Pneumothorax. Air in the pleural cavity—(1) injury 
to the chest wall, going into it from without, (2) or from 
the lung channel, as if coming out, (3) or by ulceration or 
suppuration in adjacent organs, intestines, esophagus, etc. 

Polypus. A tumor with a pedicle, as a growth in the 
ear, nose, bladder, uterus, urethra, or rectum. 

Prepuce. Foreskin; fold of skin lined with mucous 
membrane under which dirt accumulates. 

Primary Union. The clean joining of two edges of a 
wound, as in a herniotomy. One should always be very 
ambitious to have primary union of severed tendons; for 
instance, where function w r ould be seriously impaired. 
Divided nerve ends cannot have union. 

Procidentia. Prolapse, a falling down (of the uterus). 

Prolapse. A falling down (as of the rectum). 

Prostatitis. Inflammation of the prostate gland from 
old age, injuries, or gonorrhea. 

Proximal. Of the two ends of an object; the nearer to 
a chosen point. 


254 


THE OPERATING ROOM 


Psoas. Muscle of the loin and pelvis. 

Ptosis. Drooping of the eyelid with loss of nerve 
power; dropping of the intestine or stomach. 

Purulent. Not pussy. Containing pus. 

Pus. Liquid formed of dead and living bacteria and 
leukocytes; also the fluids they have thrown off in their 
conflict in a part that has been inflamed. 

Pustule. A small elevation on the skin containing pus. 

Pyaemia or Pyemia. Following septicemia fresh sup¬ 
purating foci are developed all over the body; metastatic 
abscesses. 

Pyelitis. Inflammation of the pelvis of the kidney 
(the main part). 

Pyosalpinx. A tube distended with pus. 

R 

Rachitis. Malformation of chest and bones due to im¬ 
proper nourishment. When placing a rachitic patient on 
the operating-table one is surprised to find such irregular¬ 
ities in the bones of the legs that they can hardly fit into 
the stirrups. 

Ranula. A small tumor, very troublesome, in Whar¬ 
ton’s duct obstructing the salivary fluid. 

Rectocele. A sac of relaxed vaginal wall, posterior, 
pushed down by the relaxed front wall of the rectum. 

Rectovaginal Fistula. Usually congenital; unclean; 
accompanying imperforate anus. 

Renal. Pertaining to the kidneys. 

Resolution. Return of a part to normal after some dis¬ 
eased condition, as of the lung in pneumonia. 

Retained (placenta). Left in when it should normally 
come out, also as of a soapsuds enema. 

Retroflexion. Bent backward on itself (uterus). 

Retroversion. Falling back as a whole without doub¬ 
ling on itself. 

Rupture. A bursting of a sac or blood-vessel (also of 
an inflamed appendix); the lay word for hernia; incorrect 
because there is only displacement. 


TERMS USED IN SURGICAL DIAGNOSIS 


255 


S 

Sac. A bag or the bulging cover of a cyst or tumor; 
in hernia, the bag growing around the dropped loop of 
intestine; a natural cavity. 

Sarcoma. Travels by way of the blood-vessels, to dis¬ 
tinguish it commonly from carcinoma. It is malignant 
and found in early life. It occurs in the skin, subcuta¬ 
neous tissue, subserous connective tissue, fasciae, perios¬ 
teum, and choroid of the eye most frequently. It is also 
found in the brain, cord, lymph-nodes, uterus, ovary, 
bladder, and kidney, from which last it can be projected 
into the lungs and heart. 

Sebaceous. Pertaining -to the oil-glands of the skin. 

Septicaemia or Septicemia. A condition in which bac¬ 
teria and their toxins are distributed all through the body 
by the blood and the lymph. 

Septum. A partition, may be deviated, in the nose; 
sometimes a double vagina is found with a septum be¬ 
tween the two halves. 

Seropurulent. Having partly the nature of both serum 
and pus. 

Serous. Pertaining to or resembling serum. 

Serum. Clear yellowish fluid separated from the blood 
after the coagulated fibrin is removed. 

Severed. Cut in two, as a tendon or a nerve. 

Sinus. (1) A large channel containing blood, as the 
lateral sinus, disturbed in some ear operations; (2) a 
cavity within a bone (frontal); (3) a worm-like opening 
from tissues for drainage in an old wound; an effort of 
nature to show that some foreign body has been left in, 
as silkworm-gut instead of chromic gut. 

Slough. Death and throwing off of tissue, as after a 
deep burn. 

Spasm. Sudden muscular contraction with pain. 

Stenosis. Constriction or narrowing of a passage so 
that what should normally pass through cannot, as aortic 
stenosis or stenosis of the cervix. 


256 


THE OPERATING ROOM 


Strangulated, Compressed and twisted so as to cut off 
the blood-supply, as in a hernia; black and gangrenous. 

Strabismus. Squint. Do not say “strabismuth”! 

Stricture. Narrowing of a canal from inflammation of 
its inner walls; frequently from infection, not always. 

Subinvolution. Imperfect contraction of the uterus 
after childbirth. 

Supernumerary. Extra, as of a thumb or any other 
digit sprouting out from the base of the normal one. 

Synovitis. Inflammation of the synovial membrane; 
may be suppurative. 

T 

Teratomata. Congenital growths containing all forms 
of connective tissue (cartilage, hair, skin, teeth, nails, 
bone, glands), and found in the end of the spine, head, 
neck, glands, and generative organs, probably part of 
another fetus. 

Thickening. A swelling due to old inflammation. 

Thrombosis. Organized blood-clot blocking a ve’n. 

Tight Lacing. Cause of displacement of kidneys, pan¬ 
creas, liver, and uterus. 

Torsion. Twisting, as a big tumor on its pedicle, be¬ 
coming a strangulation. 

Transposition. Wrong position from birth, as liver on 
the left, heart on the right, etc. 

Transudation. Passing of fluid through a membrane, 
as blood through its vessel walls. 

Trauma. Condition of being wounded. 

Tubal Pregnancy. Growth of fertilized ovum in the 
tube. 

Tubercle. A specific lesion produced by the germ of 
tuberculosis (the tubercle bacillus); a nipple or nodule of 
diseased tissue visible to the naked eye. 

Tuberculosis of the joints or peritoneum is operable; 
opening for drainage or exposure to direct sunlight. 

Tumors. Circumscribed new growths of tissue— 
nodular, tuberous, fungoid, polypoid, papillary, dendritic, 
or lobulated. Some are benign, others malignant. 


TERMS USED IN SURGICAL DIAGNOSIS 


257 


U 

Ulcer. Gradual death of the tissue of the skin or 
mucous membranes. 

Ulceration. Necrosis with erosion (wearing off) in¬ 
volving the surface of the skin, mucous or serous mem¬ 
brane, due to inflammation or cutting off of nutrition. 

Urachus. Remains of fetal life sometimes found in the 
abdomen during an operation for a different purpose; a 
canal about 6 cm. long, with a small opening into the 
bladder or entirely closed at that place; if there are certain 
congenital malformations the urine may flow through 
the urachus; in the adult a slight distention visible up to 
the navel shows that the urachus was never obliterated. 

V 

Varicocele. Veins of the spermatic cord dilated and 
forming twisted masses. 

Varicosity. A swollen vein, knotted and tortuous, 
resembling a bunch of grapes. 

Vascular. Having many blood-vessels. 

Vesicovaginal Fistula. Requires a special bed; an open¬ 
ing from the bladder to the vagina with constant dribbling 
of urine; very common after childbirth, due to pressure 
and necrosis before the invention of obstetric forceps. If 
a patient’s bladder is full the surgeon may snip it acci¬ 
dentally, causing a vesicovaginal fistula. Sims earned 
the eternal gratitude of his time by repairing it com¬ 
pletely with silver wire. 

Vicarious. Relating to an habitual discharge of blood 
in an abnormal part of the body, but never in the vagina, 
as a substitute for menstruation. 

W 

Walled-off. Shut in or bounded by a solid body of 
leukocytes in nature’s effort to check the invasion of 
bacteria. 

Wen. A sebaceous cyst. 

Whitlow. Same as Felon, 

17 


CHAPTER XVI 


NOMENCLATURE OF OPERATIONS 

“Call a spade a spade.” 

TERMS CREATED BY THE WORKERS OF THE OPERATING 

ROOM IN CONTRADISTINCTION TO THE TERMS USED 

IN SURGICAL DIAGNOSIS OR PATHOLOGY 

Careful Use of Terms. —The low standard in English 
set for entrance into a training-school for nurses causes a 
disagreeable condition which requires watchfulness and 
perseverance on the part of the supervisor of the operating 
room. Many pupils with limited vocabulary and powers 
of spelling pick up a new term of classic origin and re¬ 
iterate it till all other persons are bored to death. The 
well-educated are masters of many languages, but use only 
the simplest Saxon. The derivation of all new terms must 
be thoroughly learned, with prefixes and suffixes, but 
these should be used only in technical conversation, not 
played with as a new toy. A surgeon has the just right 
to ask a nurse for the definition of any term he hears her 
use. If a junior nurse asks such a question, it is sure to 
be a propos of a certain case, and she is entitled to ample, 
exact information. The name of the operation appears 
usually about five times per case: 

1. When posted in the office and on the operating-room 
calendar. 

2. When the supervisor holds morning drill in anatomy 
for all cases listed. 

3. On the slip sent to the ward, briefly specifying the 
salient features of the work done, to help the ward nurse 
care intelligently for the ether case. 

4. On the chart in three places: 

(а) Opposite the hour at which it took place in 

that day’s sequence of events to the patient. 

(б) On the patient’s discharge slip. 

258 


NOMENCLATURE OF OPERATIONS 


259 


(c) On the history sheet of operation, dictated by 
surgeon or assistant. 

5. In the operating-room register. 

The nurse should keep a record of the cases for which 
she scrubbed, by these technical names: “one iridectomy, 
one hysterectomy, one gastro-enterostomy, etc.” 

Model of Slip to Ward. —Pinned on the shirt or clipped 
to the chart goes the slip telling the ward nurse the nature 
of her duties to the ether case. 

1. Date. 

2. Patient’s name. 

3. Ward. 

4. Operator and assistant (signs). 

5. Operation. 

6. Anesthetic. 

7. Stimulation. 

8. Drainage. 

9. Condition. 

Rules for Formation of Terms Naming Operations: 

1. There are two parts to each name of an operation: 

(a) The anatomic area, where the work was done. 

( b) The nature of the work done. 

These roots or parts of words are usually classic in 
origin (Latin or Greek). There are very few, but they 
may form an immense number of combinations by 
rearranging. 

I. For example: 

(a) Anatomic area 

Chole —the bile] , , , „ ,, i, 

r cholecyst—gall-bladder 

Lyst a sac j 

(b) Ectomy—cutting off. 

(c) Otomy—cutting into. 

Therefore: 

Cholecystectomy means removal of the gall-bladder. 
Cholecystotomy means opening it and draining only. 

II. (a) Anatomic area 

Staphylo —palate, 

(6) Orrhaphy—suturing, 


260 


THE OPERATING ROOM 


Therefore, Staphylorrhaphy is repair for cleft-palate. 

To make the full name of any operation, we usually 
place the name of the anatomic part first, and the suffix, 
describing the work to be done, last. 

2. Knowing the why and wherefore helps to brighten 
what would otherwise be dull automatic work. It enables 
the nurse to reason out steps in surgical procedure, antici¬ 
pate the surgeon’s needs, reduce the patient’s shock, and 
save on ether bills. 

3. As to spelling, the usual rules of English are ob¬ 
served—final consonant doubled after a short vowel: 

Benefit, benefitted, 

Label, labelling., 

4. There are exceptions to these, in general operating- 
room conversation, as far as the casual observer could 
judge. For example: (a) An opacity of the lens is called 
cataract. But the word cataract does not become the root 
or derivative of the name of its operation. The ophthal¬ 
mologist makes an incision in the iris, out through which 
the opaque lens slips, permitting sight to be restored. 
This is properly called iridectomy , or cutting away part 
of the iris. The lens itself is not operated on, in a true 
sense. 

(6) Again, a certain tense hard condition of the eye¬ 
ball, due to the improper blocking of certain glandular 
secretions at their outlet is called glan-coma. But this is 
also relieved by iridectomy. 

5. Sometimes a correct diagnosis is not made till the 
operation is well advanced, in which case the surgeon 
posts himself for an “exploratory” in the region of the 
gall-bladder, stomach, kidney, etc., especially when malig¬ 
nant growths are suspected and frozen sections examined. 

6. If a nurse is not certain that she knows the correct 
term to use, she should use plain Anglo-Saxon. 

7. It is usually agreed upon now’ that operations must 
be named anatomically, and not after the great pioneer 
surgeons who first relieved suffering by that method. 
Surgeons are immortal in the measure of their pioneering, 


NOMENCLATURE OF OPERATIONS 


261 


in their heroism, and devotion. It seems very meager 
reward to have an operation named after one, but while 
even this is being taken away, the pupil should be taught 
a thorough lesson on the immortal work of such men as 
Sims and Bassini. 

8. Some words are misnomers, as in any other walk 
of life, due to slipshod methods of the past. 

9. Some words formed according to rule result in a 
spelling and pronunciation that seem unique. 

10. Some words require the insertion of an extra vowel 
or consonant on the principle of ease which enters into all 
parts of our language. 

11. Where two vowels are adjacent, but belong to 
different syllables (and do not combine into a diphthong) 
the dieresis is placed over the second, as oophoron, the 
ovary. 

Roots of Classic Origin: 

A. Anatomic part. 

Acteno, relating to glands (neck, groin, axilla, 
etc.). 

Chole, pertaining to bile. 

Colo, pertaining to the colon (part of large in¬ 
testine) . 

Colpo, relating to the vagina. 

Cranium , the skull, or bony covering ( not the 
brain). 

Enteron, the intestine. 

Gastro, pertaining to the stomach (where diges¬ 
tion is carried on). 

Hysteron, the uterus. 

Jejun, relating to the second part of the small 
intestine. 

Lamina, a plate or layer (referring to the pos¬ 
terior vertebral arch). 

Nephron, the kidney. 

Oophoron, the part bearing the egg (Greek, the 
ovary). Note the spelling and pronunciation 
(like oasis). 


262 


THE OPERATING ROOM 


Ophthalmo, relating to the eye. (Note two 
pairs of consonants, ph and th). Pronounced 
off-thal-mo. 

Orchi, relating to the testicle (genito-urinary). 

Osteo, bone (Latin os, ossa). There are, natu¬ 
rally, many bones, and many varieties of 
operation on each, the particular part diseased 
always being specified. Osteotomy, division 
of a bone, but to ensure proper preparation, 
the bone must be named, tibia, femur, etc. 

Ot, pertaining to the ear. 

Prod, pertaining to the rectum. 

Prostat, pertaining to the prostatic gland 
(genito-urinary). 

Rhino, pertaining to the nose. 

Salpinx, the fallopian tube. 

. Spermato, relating to the semen. 

Tars, pertaining to the instep. 

Ten, pertaining to tendons (in the eye, wrist, 
finger, etc.). 

Splanchno, pertaining to the viscera. 

Trachelo, relating to the cervix, or neck of the 
uterus. There is no word beginning with 
cervi to denote these operations. 

Tracheo, pertaining to the windpipe only. Note 
difference from one above. 

Uretero, relating to the two pipes or tubes from 
the kidneys to the bladder. 

Urethr, relating to the single canal from the 
bladder to the outside. 

Vas, the sperm duct. 

B. Nature of Work Done. 

-ectomy (Greek, cutting off), complete removal of 

the part specified. 

-orrhaphy (Greek, suture) sewing up. 

-ostomy (Greek, stoma, a mouth) making a new 

opening into an organ; usually in the intestinal 

tract, to get by an obstacle, likely a malignant 


NOMENCLATURE OF OPERATIONS 


263 


growth, to pass the contents along, for diges¬ 
tion, assimilation and excretion, gastrostomy, 
opening into stomach, through which food is 
taken, instead of by mouth. 

-otomy (Greek to cut) cutting into, for drainage, or 
to reduce size. 

-pexy, fixation to another organ. 

-plasty (Greek, meaning form or shape) , cutting 
and trimming off; straightening and smoothing, 
reducing to normal, for cosmetic effect, for de¬ 
formity, for comfort, for repair, etc. (not pre¬ 
ceded by disease). 

-stasis (Greek, causing to stand) fixation. 

Glossary of Terms Made from These Roots: 
Adenectomy. The excision of a gland. 

Cholecystectomy. Excision of the gall-bladder. 
Coccygectomy. (kok-sij-jectomy). Note spelling, also 
cutting off long coccyx. 

Colostomy. Formation of artificial anus by opening 
into the colon. 

Colpeurysis. Dilation of the vagina by the colpeurynter 
(an inflatable bag or sac). 

Colporrhaphy. Suture of the vagina. 

Craniectomy. Removal of strips or pieces of cranial 
bones in microcephaliac fetus (obs.). 

D. and C. : 

(1) In a non-pregnant uterus, for tonicity, or explora¬ 

tion for malignant growths. 

(2) In a pregnant uterus only for honest therapeutic 

measures and reportable to the Board of 
Health—often questionable, a cloak for abor¬ 
tions. 

Enterostomy. Formation of artificial opening into the 
intestine, through the abdominal wall. 

Gastro-enterostomy. Opening from stomach into in¬ 
testine to get past some obstruction above the latter. 
Gastrectomy. Excision of whole or part of the stomach. 


264 


THE OPERATING ROOM 


Herniotomy. Radical cure of hernia by repair of muscles 
to prevent protrusion of viscera. 

Hysterectomy. Excision of uterus (abdominal or vagina? 
route). 

Iridectomy. Misnomer—should be qualified as ‘ ‘par¬ 
tial” or “incomplete.” 

Jejunostomy. Making an artificial opening into the 
jejunum, through the abdominal wall. 

Jejunojejunostomy. Sewing two parts of the same gut 
together and making a mouth afterward at the point of 
junction so as to catch any portion of the intestinal 
contents lurking in the “vicious circle,” like a plumber’s 
trap, left above after a gastrojejunostomy. (Show by 
drawings.) 

Laminectomy. Removing the posterior vertebral arches. 

Myomectomy. Excision of uterine myoma. 

Nephrotomy. Incision into kidney (abdominal or 
lumbar route). 

Nephropexy. Fixation of floating kidney. 

Nephrolithotomy. Removal of renal calculus. 

(Esophagotomy. Opening into oesophagus. Note spell¬ 
ing. 

Oophorectomy. Excision of ovary (must specify left or 
right). 

Ophthalmoplasty. Plastic surgery of the eye or acces¬ 
sory parts. 

Ophthalmostasis. Fixation of eye by special instrument 
to permit operation. 

Orchidectomy . Castration. 

Osteectomy. Excision of portion of a bone. 

Otoplasty. Plastic surgery of the external ear. 

Ototomy. Dissection of the ear. 

Panhysterectomy. Total extirpation of the uterus (only). 

Proctectomy. Excision of the anus or rectum. 

Proctopexy. Fixation of rectum by sutures to another 
part. 

Prostatectomy. Excision of prostate gland. 

Pyloroplasty. Sewing and cutting around the pylorus. 


NOMENCLATURE OF OPERATIONS 


265 


Rhinommedomy. Excision of inner canthus of the eye. 

Rhinoplasty. Plastic operation on the nose. 

Salpingectomy. Excision of fallopian tube (must specify 
left or right). 

Spermatocystotomy. Surgical incision of seminal vesicle. 

Splanchnotomy. Dissection of viscera. 

Splenedomy. Removal of spleen (interesting to note 
length of life afterward). 

Tarsedomy. Excision of tarsal bones. 

Tenonedomy. Excision of part of a tendon. 

Tenotomy. Cutting a tendon. 

Tenorrhaphy. Suturing two ends of a divided tendon 
(very delicate and important). 

Thoracotomy. Opening for free pus in the pleural cavity. 

Trachelorrhaphy. Repair of laceration of cervix uteri. 

Tracheotomy. Cutting into the trachea (so that breath¬ 
ing may go on). 

Tonsillectomy. Removal of tonsils (snare). 

Tonsillotomy. Old methods of slicing off only the tops. 

Ureterotomy. Incision of the ureter. 

Urethrotomy. Cutting a stricture of the urethra (char¬ 
acterized as internal , etc.). 

Vasectomy. Resection of the vas deferens. 

The best specimen of these coined words is “hystero- 
salpingo-oophorectomy,” removal of uterus, tubes, and 
ovaries (avoided as long as possible). 

Special Verbs Relating to Operating: 

Anastomose. To join, end to end, as two sound pieces 
of gut. 

Bloodless operating. Straightening limbs in congenital 
hip-disease; no external wound. See chapter on Ortho¬ 
pedics. 

Bone-graft. Inlay, transplanting. 

Quite recent discovery; splicing an old, diseased 
bone, or injured member, with a sound piece, 
taken usually from tibia or fibula; tuberculosis 
or non-united fracture. 

Bone-plate. Metal plate (varied sizes) screwed in place 


266 


THE OPERATING ROOM 


with steel screw-nails into two approximated ends of 
broken bone. 

Cesarean section. Note the spelling—mode of Julius 
Caesar’s birth. 

Circumcise. Excise the prepuce of penis—without 
anesthesia in very young infants. 

Clamp and cautery. Operating-room slang for operation 
on hemorrhoids. 

Dilate. To increase diameter (vagina or cervix), “dila¬ 
tion” is correct English. 

Excise. To cut away, usually on or near the surface. 

Extirpate. To cut away deep-seated parts (uterus). 

Graft. To place a small portion of skin, bone, nerve, 
periosteum, etc., to cover a defect in a corresponding 
tissue. 

Immobilize. To fix, render motionless with splint, sand¬ 
bags, or plaster cast. 

Incise. To cut into, for drainage (as a boil). 

Inlay. (See Graft.) 

Kraske. Surgeon who relieved cancer of the rectum 
by removing the coccyx and part of the sacrum to form a 
new opening above the malignant growth. 

Ligate. One method of treating hemorrhoids—then 
excising. 

Needling. On the eye, following the primary irid¬ 
ectomy, lacerating a cataract with a needle, to afford 
entrance to the aqueous humor and cause absorption of 
lens. 

Resect. Misnomer—used to mean removal of piece of 
organ, bone, etc. (empyema). 

Trephine or trepan. Sawing into the skull, generally 
in three disks, to break off the small bridges remaining 
and minimize shock to the patient. 


CHAPTER XVII 

LISTS OF INSTRUMENTS FOR OPERATIONS 

Dissecting Set: 

1 scalpel to suit, 

1 probe, 

1 grooved director, 

2 single tenacula, 

2 dissecting scissors, 

1 mouse-tooth forcep, 

1 plain forcep, 

2 retractors to suit, 

Hemostats, Ochsner and Kelly, in numbers to suit. 

A dissecting set + the instruments required for the 
specified anatomic region -f- suture set = total number 
required for any operation. 

Nursed set (when, more than suture nurse, assisting 
at wound): 

1 pair straight scissors, 

2 needle-holders with needles, 

3 sponge sticks, 

2 ligature carriers (aneurysm needles), 

1 suture forceps, 

4 towel clips. 

Decompression—Cranium—Exploratory, etc.: 

(a) Instruments: 

Scalpels, 

Mouse-tooth forceps, 

Anatomic forceps, 

Artery clamps, 

Scissors, 

Sharp retractors, 

Periosteal elevators, 

Trephines, 

Probes, 


267 * 


268 


THE OPERATING ROOM 


Gigli saws with handles (Figs. 34, 35), 
Bullet searcher (p. r. n.), 

Rongeurs, 

Sharp curets, 

Mallet, 




Fig. 35.—Handles for Gigli 
saw (in pairs). 


Chisels, 

Gouges, 

Aspirating-needles and syringe, 
Needle-holder (Fig. 36), 
Needles. 



Fig. 36.—Richter needle-holder (5§ to 8 inches). 


(6) Needles: 

(1) Small round body for meninges with very 

fine catgut. 

(2) Medium-sized curved Hagedorn, for scalp, 

with silkworm-gut or silk, to be removed, 
or 

(3) Curved needle with cutting edge. 





LISTS OF INSTRUMENTS FOR OPERATIONS 


269 


(c) Accessories: 

(1) Blood-pressure apparatus (sphygmoman¬ 

ometer) for all intracranial work, 

(2) Lighting of room, 

(3) Headlight, 

(4) Sand-bags, 

(5) Sterilize electrodes; cover all electric appli¬ 

ances near wound with sterile gauze, 

(6) Clippers, safety razor, and good common 

razor, with scissors, 

(7) Hair at edge of shaved area plastered down 

with gauze strip steeped in collodion. 

(d) Sterile Goods: 

(1) Towels, laparotomy sheet, dressings, starch 

bandage as final dressing, wet well to set 
firm, 

(2) Bandage around brow for constriction, 

(3) Bone wax. 

(e) Notes. —Head nurse in morning class to make a 

drawing of the various layers—hair, scalp, 
periosteum, bone, dura mater, pia mater, 
arachnoid membrane, and brain tissue. 

(/) Drains: 

Twisted catgut drains. 

Rubber tissue also. 

Mastoidotomy (New York Eye and Ear Infirmary 
notes): 

(a) Instruments (including enough for the assistant): 
5 rongeurs (McKernon, Adams, Janvier, Pyle, 
bulldog), 

1 mallet, 

3 chisels (graded), 

3 gouges (graded), 

4 spoon curets (graded), 

2 ring curets (graded), 

2 periosteal elevators, 

2 sharp retractors, 

X mastoid self-retaining retractor, 


270 


THE OPERATING ROOM 

2 Mayo retractors, 

2 mouse-tooth forceps, 

2 thumb forceps, 

Michel clips, 

2 grooved directors, 

2 probes, 

2 scalpels, 

2 scissors (straight blunt and curved blunt), 

1 needleholder, 

12 artery clamps, 6 curved, 6 straight, 

1 mastoid syringe (metal ground, no washers), 
6 needles. 

(b) Needles: 

(1) 2 small curved round body for possible use 

of catgut Nos. 1 and 2, in narrow, deep 
cavities. 

(2) 4 medium-sized full-curved Hagedorn, for 

silkworm-gut for the skin—scalp is tough, 
needing stout materials. 

(3) Silk suture material in readiness. 

(c) Accessories: 

Nurse’s set. 

Long uterine dressing forceps are very handy 
to get goods out of jars. 

Glass basin for alcohol, 95 per cent. 

Medicine glass, smear glasses for microscopic 
examination of pus when found, slides, 
swabs. 

Pitcher, saline. 

Carbolic acid, 5 per cent., in basin to steep old- 
fashioned syringe with leather washers. 
Sand-bag—small, flat, special—under the neck. 

(d) Sterile Goods: 

Laparotomy sheet, towels. 

3 bundles special mastoid tips. (See chapter 
on Dressings.) 

Special mastoid dressing. 

Plain gauze packing, very narrow. 


LISTS OF INSTRUMENTS FOR OPERATIONS 


271 


Iodoform packing. 

One plug iodoform gauze for the sinus. 

One narrow strip, plain gauze for the canal. 

(e) Notes: 

Usually the retractors are held by a pupil. 

Special room, or darkened room. 

Watch the ventilation. 

In applying bandage, let down head of table, 
hold patient gently by the hair and the 
shoulders. 

Watch for pus—do not wipe it away—put on 
slide. 

Infections from this may travel all the way 
down the sternocleidomastoid. 

Ward nurse must send patient up, free from 
pediculi, with hair combed and braided in 
the special mastoid manner, slanting toward 
the well ear. 

Hair must be fastened down along the edge of 
the shaved area by a strip of gauze steeped in 
collodion, pressed on, and let dry. 

Removal of Ossicles of Middle Ear —“Radical”— 
Malleus, Incus, Stapes: (Same as for mastoidotomy, plus): 

(a) Instruments: 

4 cotton applicators, 

2 flap knives, 

Specula (graded). 

(b) Needles: 

Use 10-day chromic gut No. 10. 

(c) Accessories: 

(1) Skin-graft taken from patient’s thigh, into 

middle ear, which is denuded and now 

exposed permanently. 

(2) Fine prepared sterilized animal membrane 

to cover graft to protect.while “taking.” 

(3) Examine thigh, and renew dressing if 

required. 


272 


THE OPERATING ROOM 


(d) Sterile Goods: 

(1) Gauze strip for retractor, to pull ear for¬ 

ward, out of the way. 

(2) Mastoid tips—dressing. 

Resection of Jugular Vein (following sinus thrombosis 
after mastoiditis): 

Always an emergency operation, chills and fever indi¬ 
cating a septic thrombus in the lateral sinus, to relieve 
which a portion is excised, and collateral circulation 
relied upon. 

(a) Instruments: 

Infusion set , for shock, 

Blunt retractors, so as not to abrade or punc¬ 
ture the vein, 

Extra stock of artery clamps, 

Scrubbing-up set, 

Dissecting set, 

Needle-holder, 

Nurse’s set. 

(b) Needles: 

One with stout ligatures of plain catgut No. 3, 
to tie around the two ends of the vein before 
excising thrombus. 

(c) Accessories: 

Saline, cold and hot. 

Iodoform and boric acid powders in sterile 
insufflators. 

(d) Sterile Goods: 

Plug of gauze for the sinus. 

Flat gauze. 

Square cotton pads. 

Neck bandage—2 inch. 

Safety-pins and adhesive. 

(/) Notes: 

Save the specimen for culture and immediate 
microscopic examination. 

Have hot-water bottles in double flannel cov¬ 
ers and other stimulation. 


LISTS OF INSTRUMENTS FOR OPERATIONS 


273 


Skin-grafting (compiled from notes while assisting Dr. 
E. B. Dench), New York Eye and Ear Infirmary: 

(а) Instruments: 

Special skin-grafting razor, with thin edge, 
thick back, and handle adjusted at a slant, 
Tissue curet, 

Scissors blunt, curved on the flat, 

3 spatulae, assorted sizes, 

2 packers (to pick at skin on spatula), 

4 slides, 

Cotton applicators, 

One pipet, 

One medicine-dropper. 

(б) Accessories: 

Tepid saline in glass dish, , 

Silver leaf (in book), sterile, 

Rubber tissue, 

Adhesive straps. 

(c) Sterile Goods: 

Towels, sponges, flat compresses, 

Roller dressing, 

Pledgets of aristol, sterile, in glass test-tubes, 
dropped to place. 

(i d ) Notes .—Assistant keeps saline dropping on razor 
and on skin-grafts (equivalent to life blood), 
scissors or curet used on burned areas to 
level off excessive granulations. 

Incision of Brain Abscess (following mastoidotomy, 
etc.): 

(a) Instruments: 

2 brain knives, curved and straight. 

Spade retractors, square, very large. 

Clamps. 

Encephaloscopes, three sizes. 

Radical for Infected Frontal Sinus. —A radical opera¬ 
tion is made by a wound between the brows; a conserva¬ 
tive or indirect is done intranasally. An acute infection 
at its first height may be successfully treated intra- 
18 


274 


THE OPERATING ROOM 


nasally, but a chronic or neglected acute case must be 
treated radically. 

(a) Instruments: 

Small trephine, diameter of not over 5 mm. 
Scalpel. 

Thumb forceps (dissecting). 

6 artery clamps. 

1 periosteal elevator. 

Chisels and gouges (graded). 

1 mallet. 

Electric burr or drill, preferred by some 
operators. 

Curets (graded). 

Intranasal bone forceps of various types. 
JVound retractors. 

Probe. 

Scissors (straight and curved on the flat). 
Needle-holder. 

Needle. 

(I b ) Needle: 

Hagedorn curved, with silk gut, for the 
skin. 

Iridectomy (for glaucoma or cataract)—partial special 
method of anesthetizing by cocain at fixed intervals, 
previously: 

(а) Instruments (usually owned by operator): 

Right or left speculum. 

Fixation forceps. 

Cataract knife. 

Iris forceps. 

Iris scissors. 

Iridectome. 

Cj^stotome. 

Spoon. 

Iris repositor. 

(б) Accessories: 

(1) 2-inch bandage best grade gauze, double 
figure-of-8. 


LISTS OF INSTRUMENTS FOR OPERATIONS 


275 


(2) Special woven woolen or linen bandage, 

p. r. n. 

(3) Mask of black satin over all. 

( c ) Sterile Goods: 

(1) Eye pads, flat gauze to receive lens when 

expressed. 

(2) Cotton moistened in sterile water for spong¬ 

ing, to leave no threads. 

(d) Notes: 

(1) No pressure on eyeball. 

(2) Assistant must be in good physical shape, 

to hold lens steady. 

(3) Be sure which eye is to be operated on. 

Safeguard the good eye —cover it. 

(4) Keep blood washed off instruments during 

operation. 

(5) By instilling confidence in the patient his 

nervousness is reduced and he will not 
“squeeze” so much. 

(6) The ethical behavior of the operating-room 

personnel largely controls the patient’s 
behavior and the success of the result. 

(7) All orders regarding catharsis, diet, wraps, 

etc., must be carefully written. 

(8) The patient must be assisted in keeping 

his orientation by being told the direc¬ 
tion in which each portion of the room, 
furniture, etc., is from him. 

(9) He must not he allowed to catch cold and 

sneeze . 

(10) No drafts—gentle handling—good if 

done on his own bed. 

(11) Cleanse ivory handled eye knives in ben¬ 

zine, or in soapy water—metal handled 
knives in alcohol—rinse and wipe on 
soft old linen. 

(12) Test knives on a drum for edge—kid 

glove wrist stretched over a napkin 
ring or tiny embroidery hoop. 


276 


THE OPERATING ROOM 


(13) Boil blunt instruments only. 

(14) The whole iris is not removed, merely a 

small section, which added to the pupil 
looks like a keyhole. 

(15) Cork protects delicate ends of special 

knives. 

Removal of Foreign Body in Eye: 

Intra-ocular, 

Intra-orbital. 

The equipment of a small, clean, plain room for such 
important work fills a need in a community and brings 
or keeps a higher type of surgeon and patient, besides pre¬ 
paring nurses more broadly to do their community duty 
after graduating. 

Accessories: 

Magnet—Grant, Haab. 
x-Ray plate and chart. 

Non-magnetizable instruments. 

Intense local illumination on stand or bracket. 
Suction device. 

Strabotomy —correction of strabismus (convergent; 
divergent): 

(а) Instruments: 

Speculum. 

Fixation forceps. 

Conjunctiva forceps and scissors. 

Strabismus hook. 

Tendon scissors and sutures. 

Nurse’s set. 

(б) Needles: 

(1) Small curved. Have ready early, with 6 
black silk sutures (iron dyed) 8 inches 
long—called conjunctival sutures. 

(c) Accessories: 

Basin of bichlorid of mercury, 1 : 5000. 
Carbolic acid 1 : 20. 

Sterile water, adrenalin chlorid, argyrol, 20 per 
cent, fresh. 


LISTS OF INSTRUMENTS FOR OPERATIONS 


277 


Tincture of green soap. 

Adhesive. 

(d) Sterile Goods: 

Special pattern sponges. 

Special fine cotton. 

Gowns, gloves, towels, sheets. 

Special eye bandages. 

Enucleation of Eye: 

(а) Instruments: 

Speculum. 

Fixation forceps. 

Conjunctiva scissors. 

Strabismus hook. 

Tendon scissors. 

Stronger scissors. 

(б) Needle: 

Small round, with conjunctival sutures as 
in Strabotomy. 

(c) Sterile Goods: 

(1) Pressure pad to stop oozing—special cut. 

(2) Two flat pads of cotton, diameter 2\ 

inches, moistened in boric acid (2 per 
cent.) to lay in the vacant socket—then 
dry absorbent cotton. 

(3) Special eye bandage and mask. 

(4) Cover on the good eye. 

( d ) Notes .—Mark carefully the eye to be enucleated. 
Submucous Resection of Nasal Septum: 

(a) Instruments: 

Nasal speculum. 

Metal applicators for the preliminary cocain- 
ization, to swab strong cocain on the mucous 
membrane. 

Wooden applicators, previously wound with 
cotton on both ends for wiping blood from the 
field during operation (several dozen steril¬ 
ized and ready for use). 

Septum knife. 


278 THE OPERATING ROOM 

Elevators, of which the Freer and the Killian 
are the most common types (sharp and dull). 

Ballenger swivel knife (two sizes). 

Speculum or retractors for separating the flaps. 

Forceps (various types) for removing portions 
of the bony and cartilaginous parts of the 
deflected septum. 

Chisels (flat and grooved). 

Mallet. 

Nasal dressing forceps. 

Syringe of capacity 5 c.c. if employing injec¬ 
tion method of anesthetization. 

Needles. 

(b) Needles: 

Septum or intranasal needles, for the insertion 
of sutures—silk sutures. 

(c) Sterile Goods: 

Gauze strips, plain. 

Iodoform strips or 

Dr. August Beck’s rubber nasal packing bags, 
to prevent hemorrhage (shape of a shep¬ 
herd’s purse, made on the principle of the 
colpeurynter, or Voorhees’ obstetric bags, in¬ 
serted, then dilated with sterile water, stems 
tied). 

Lubricant—K. Y. (on bags). 

Adenoidectomy + Tonsillectomy: 

(a) Instruments: 

Mouth-gag. 

Tongue depressor (metal). 

Headlight. 

Adenoid forceps. 

Adenoid curet. 

6 sponge forceps. 

Long blunt scissors curved on the flat. 

Tenaculum forceps. 

2 tonsil snares (one on each, before snaring). 

Tonsil dissecting knives (right, left). 


LISTS OF INSTRUMENTS FOR OPERATIONS 


279 


Wires to thread snares. 

Lovell tonsillar hemorrhage needle. 

Tonsil-seizing forceps. 

Pillar retractor. 

Hemostats. 

Electric suction device (prevents swallowing 
of blood). 

Needle: 

Catgut ligatures. 

Extra heavy black silk ligatures in Lovell 
needle, for circular suture around oozing 
area. 

(c) Accessories: 

Crystals of 

Cocain for local anesthesia, 

Novocain. 

Carbolic acid 1 : 20 for sharp instruments (?). 

Medicine-glass (graduated). 

Dropper. 

Syringe. 

Applicators. 

Cotton. 

Alcohol, 95 per cent. 

Adrenalin 1 : 1000. . 

Bichlorid of mercury 1 : 5000. 

Rubber cap. 

Gown neck loose. 

Rubber sheet, long and narrow to turn patient 
(from left shoulder out over chest, under 
right shoulder, and at least \ yard out from 
left shoulder again). 

Waste pail with sieve to drain sponges. Towels 
in basin of ice and water (scant water). 

Coagulometer—to test for hemophilia—to de¬ 
termine the rapidity of coagulation of the 
blood. Hemophilia is frequently unsus¬ 
pected, and is the chief menace in tonsillec¬ 
tomy. 


. 280 


THE OPERATING ROOM 


(d) Sterile Goods: 

Laparotomy sheet, gowns, gloves. 

Sterile towels, sterile water. 

Numerous small sponges mounted on sponge 
sticks. 

(e) Notes: 

All tonsil cases should have two successive 
negative throat cultures before operation. 

Protect walls and floor. 

Do not throw out specimens: they prove the 
need of operation. 

Keep patient at extreme right of table—wipe 
his nose frequently, to let air through, with 
downward stroke. 

Let the air clot the vessels in the adenoid area. 

Send patient on stretcher face downward, to 
bed, and keep so, in bed. 

Incision of Pharyngeal Abscess (same method also for 
quinsy or peritonsillar abscess): 

(а) Instruments: 

Straight bistoury. Wind all the blade except 
first half inch of the tip, with adhesive, to 
prevent going in too far, on account of the 
great vessels in the vicinity. 

Tracheotomy set—have ready, then it will not 
be needed. 

(б) Accessories: 

Pus basin—try to save and show specimen. 

If patient chokes, use artificial respiration. 

Hemorrhage may ensue, in which case proceed 
as in Adenoidectomy + Tonsillectomy. Let 
patient sit up in bed, against back-rest. 

Turn him quickly to the diseased side, so that 
the pus will not cross the epiglottis. 

Lights—rubber cape around patient’s neck. 

Back-rest and additional pillows. 

Waste pail. 

Mouth-wash. 


LISTS OF INSTRUMENTS FOR OPERATIONS 


281 


Tracheotomy: 

(a) Instruments: 

Scalpel. 

2 mouse-tooth forceps. 

8 artery clamps. 

1 grooved director. 

1 trachea forceps. 

1 trachea spreader. 

Medium and small sharp retractors. 

Small blunt retractor. 

Curved and straight scissors. 

Probe. 

1 smooth dressing-forceps. 

Needle-holder and needles. 

Tracheotomy tubes, assorted sizes, with their 
inner tubes, and tapes. 

(b) Needles: 

Silkworm-gut in Hagedorn needles. 

(c) Accessories: 

Tie tapes under ear. 

Split compress soaked in soda bicarbonate solu¬ 
tion around tube. 

One thin compress, intact, moistened with 
same, over. 

Oiled silk bib. 

Pheasant’s feathers to clean permanent tube. 
Remove the other very often, to clean—meas¬ 
ure it on the feather and never put feather 
in any farther. 

Do not tickle the trachea. 

Do not expose the patient’s chest and invite 
pneumonia. 

(d) Sterile Goods: 

Laparotomy sheet, gowns, gloves, towels. 

(e) Note.—Never boil a hard black rubber tube (they 

straighten). 


282 


THE OPERATING ROOM 


Breast Amputation: 

(а) Instruments: 

Dissecting set. 

Very large number of artery clamps. 

36 hemostats. 

12 Ochsner. 

8 Kelly. 

Ligature carrier. 

5 shallow retractors (rake). 

Needle-holder and needles. 

(б) Needles: 

(1) Usually curved Hagedorn or cutting edge— 

may be straight Hagedorn—with silk or 
silkworm-gut for skin. 

(2) Ligatures of plain catgut No. 1—very 

many—every vessel is tied off. 

(3) Tension sutures (silkworm-gut) long, at 

choice of surgeon. 

(c) Accessories: 

(1) Special breast binder (Figs. 28, 29, pp. 229, 

230) with a sleeve for the affected side, 
the sleeve being split on the upper side 
and fastened with tapes, to hold all 
axillary dressings secure. 

(2) 4- or 6-inch gauze and muslin bandages. 

(3) Hot saline towels on large denuded area. 

(4) Be prepared for hemorrhage and shock. 

(5) An additional nurse holds the arm above 

the patient’s head. 

(6) Do not allow orderly to be present. 

(7) A very large area must be prepared for 

this operation (per House Rules). 

(d) Sterile Goods: 

(1) Large gauze pads. 

(2) Cotton pads. 

(3) Cotton under hand, axilla, and elbow, * to 

support and prevent friction. 

(e) Drains. —Tubes. 


LISTS OF INSTRUMENTS FOR OPERATIONS 


283 


Aspiration; Incision; Resection of Rib (in empyema): 

(a) Instruments for Aspiration: 

Syringe and needles in good order (Figs. 37, 38). 

Sponge forceps. 

(b) Accessories: 

Iodin, collodion, large graduate to measure pus 
(may be unsterile)—rubber sheet to protect 
patient and bed—assorted basins to hold 
pus—camehs-hair brush. 



Fig. 37.—Potain’s aspirator, 60 c.c.—metal barrel and metal piston, 
three needles, one stop-cock, one trocar, and tubing. 


(c) Sterile Goods: 

Cotton, gauze, towels, small glass graduate for 
specimen to laboratory. 

(i d ) Notes: 

Prepare patient posteriorly on side affected. 
Set a child up over a nurse’s shoulder. 

(a) Instruments for Incision: 

Scalpel. 

Hemostats. 

Curved scissors. 


















THE OPERATING ROOM 


Sharp retractors. 
Mouse-tooth forceps. 
Thumb forceps. 
Needle-holder. 
Needle. 


( b ) Needle: 


Curved Hagedorn for skin, with silkworm-gut 
ligatures, catgut No. 1, plain on round 
needles. 



Fig. 38.—Bottle for Potain’s aspirator, 500 c.c. 

(c) Accessories: 

(1) Lay child on good side, resting her anterior 

chest wall on the rubber-covered pillow, 
bringing her arm forward so that she does 
not lie on it . 

(2) Note change in color, respirations: point 

out all such data to pupils. 

(3) Pus basin—small sterile graduate—large 

uiisterile graduate. 














LISTS OF INSTRUMENTS FOR OPERATIONS 


285 


(d) Drains: 

Drainage-tubes. 

(а) Instruments for Resection of Rib: 

Add to set for incision: 

Periosteal elevator. 

Costotome (rib-cutting). 

Bone hook. 

1 rongeur. 

1 costal raspatory. 

1 bone-cutting forceps. 

Safety-pins for drains. 

(б) Accessories: 

(1) Rubber dam—before applying it, use 

(2) Unguentin or boralid to smear skin. 

(3) Bottles to blow water to and fro, for chest 

expansion. 

(c) Drains: 

Drainage-tubes—empyema button (spool). 
Politzer bag and tube, as of oxygen tank, the 
latter to produce vacuum and extract 
pus. 

(d) Sterile Goods: 

Pads, towels, sponges, sheet, gowns, gloves, etc. 
Appendectomy. —Take as simplest of models for any 
laparotomy. 

(a) Instruments: 

Scalpel. 

Mouse-tooth forceps. 

Plain forceps. 

Artery forceps. 

Sponge-holders. 

Retractors (small, also deep narrow pair). 
Needle-holder. 

Safety-pins for drains. 

Intestinal forceps (Fig. 39) to grasp colon 
(rubber tips). 

Ligature carrier. 

Scissors, curved and straight. 


286 


THE OPERATING ROOM 



Fig. 39.—Viscera forceps. Method of 
covering jaws with rubber tubes. 



9 


Fig. 40. 



Fig. 41. 

Figs. 40, 41. — Michel’s 
suture clips and forceps. 


Probe. 

Towel clamps. 
Needles. 













LISTS OF INSTRUMENTS FOR OPERATIONS 


287 


( b ) Needles: 

(1) Small round with plain catgut No. 1 for 

peritoneum. 

(2) Stout short round with chromic gut No. 2 

for muscle. 

(3) Straight cambric, or fine round intestinal 

needle, with fine silk for purse-string 
suture to invaginate the stump. 

(4) Long, heavy curved needles for through- 

and-through outer sutures, especially if 
around drainage-tubes, or 

(5) Michel clips with special forceps (Figs. 

40, 41). 

(6) If patient is a child, use smaller needles and 

suture material. 

(7) Ligatures, of plain catgut No. 1, for ab¬ 

dominal wall, and chromic catgut No. 2, 
to ligate appendix. 

(c) Accessories: 

(1) Specimen dish. 

(2) Carbolic acid and alcohol to cauterize 

stump, or 

(3) Paquelin cautery. 

(4) Saline. 

(5) Outfit for lavage. 

(6) Equipment to take culture for pus (sterile 

tube, applicators, slides). 

(7) Adhesive. 

(d) Drains: 

Drainage-tubes. 

Cigarette drains—cut very simply from rubber 
sheet and handed in the bite of a sponge 
stick to the assistant who may or may 
not wind it with gauze. 

(e) Sterile Goods: 

(1) Split compress, 

(2) Iodoform strip to cover wound, 

(3) Rolled gauze to wall off. 


288 


THE OPERATING ROOM 


(4) Tape sponges, or 1 long roll fed from 

pocket in sheet (no counting) (Fig. 25, 
p. 214). 

(5) Gowns, gloves, 3 table sheets (stands, 

tables): 

1 large laparotomy sheet. 

1 small laparotomy sheet. 

Packages of tape sponges. 

Packages of small sponges. 

Cholecystectomy, Cholecystotomy, Choledochotomy: 

(a) Instruments: 

Dissecting set. 

Long stout gall-stone probes. 

Gall-stone spoons (Fig. 42). 

2 gall-stone forceps (with rubber tubing, fine 
para, to cover). 

Gall-bladder clamp (with rubber tubing). 

4 Allis forceps. 

Long sounds. 

Artery clamps. 

Aspirating syringe and needles, or 
Trocar and cannula. 

Sponge forceps. 

Scissors, blunt, curved, straight. 

2 large kidney retractors. 

Needle-holders, two sizes, with needles. 

(b) Needles: 

(1) Small round body, full curved, for deep 

work on gall-bladder, with fine silk. 

(2) As in appendectomy. 

(3) Small hemostatic needle, in opening duct, 

with silk. 

(c) Accessories: 

(1) Cautery, carbolic acid, and alcohol. 

(2) Specimen dish. 

(3) Rubber tissue apron. 

(4) Adhesive in large quantities (allow for 

distention). 


LISTS OF INSTRUMENTS FOR OPERATIONS 


289 



19 








290 


THE OPERATING ROOM 


(d) Drains: Drainage-tubes. 

(e) Sterile Goods: 

(1) Sterile pus basin. 

(2) Packing, plain gauze, 2 widths. 

(3) Gauze to wall off. 

(4) Tape and small sponges. 

(5) Iodoform to cover incision. 

Gastrostomy, Gastro-enterostomy, Gastrectomy, etc.: 

(а) Instruments: 

Dissecting set. 

Retractors larger than in Appendectomy. 
Sponge forceps. 

Artery clamps. 

Ligature carrier. 

Scissors, curved and straight. 

2 stomach clamps (Fig. 43). 

2 intestinal clamps. 

Towel clamps. 

Needle-holder. 

Needles. 

(б) Needles: 

(1) Straight needles (cambric) for fine silk. 

(2) Small round body intestinal needles with 

No. 1 plain for peritoneum. 

(3) Ligatures, chromic, Nos. 2 and 3. 

(c) Accessories: 

(1) Outfit for lavage—tube, pus basin, pail, 

pitcher of tepid water, rubber cape. 

(2) Saline. 

(3) Adhesive. 

( d ) Drains: Drainage-tubes, p. r. n. 

(e) Sterile Goods: Cotton pads, fluffed gauze, tape 

sponges, gauze rolls to wall off; plain 
gauze packing, small sponges. 

(/) Notes: 

Live finely corrugated black pararubber tubes 
are boiled in a piece of muslin in a bunch 
by themselves, with the instruments, and 


LISTS OF INSTRUMENTS FOR OPERATIONS 


291 


then drawn on the ends of all intestinal 
clamps. These rubbers must be counted 
before operation and before suturing, 
lest one be left in the patient. The deli¬ 
cate structure of the intestine can be 
fatally injured by metal corrugations. 

Hysterectomy: 

(а) Instruments: 

Dissecting set. 

Retractors, three sizes, including large supra¬ 
pubic and self-retaining mechanical, which 
are screwed open, to save employing a person. 

6 sponge forceps. 

Artery clamps, 6 long straight, 6 long curved, 
12 small. 

2 aneurysm needles, right and left (Fig. 44). 

1 bladder sound (to mark the top of the blad¬ 
der). 

1 uterine dressing forceps to draw down drain 
(thrust into vagina by nurse with glove). 

Vulsella, extra strong (Fig. 45). 

Aspirating syringe and needles (when indi¬ 
cated). 

Pedicle clamps. 

Blunt straight scissors. 

Blunt scissors curved on the flat. 

Sharp scissors (straight and curved). 

Needle-holder. 

Needles. 

(б) Needles: Same as in Appendectomy—sutures for 

peritoneum, fascia, through-and-through, 
skin, intra-abdominal, intestinal ligatures— 
braided silk for pedicle—plain catgut No. 2 
for adhesions—plain catgut, No. 4, for broad 
ligaments—linen or silk ligatures. 

(c) Accessories: 

(1) Trendelenburg—provide many footstools, 
graded in height and length. Be pre¬ 
pared for collapse of patient. 


292 


THE OPERATING ROOM 



(2) Cautery. 

(3) Carbolic acid and alcohol for cauterization 

of stump. 

(4) Extra glove for nurse (guiding packing in 

special cases). 



























LISTS OF INSTRUMENTS FOR OPERATIONS 293 


(5) Hot saline constantly. 

(6) Adhesive. 

(d) Sterile Goods: 

(1) Sponges, gauze packing, tape sponges, 

gauze roll to wall off, or long roll fed 
from pocket in laparotomy sheet as in 
Appendectomy. 

(2) Infusion set. 

Cesarean Section: 

(а) Instruments for Mother: 

Dissecting set. 

2 large clamps for the cord. 

2 aneurysm needles. 

Scissors, straight and curved. 

Sponge forceps, very many. 

Needle-holder. 

Needles. 

(б) Needles for Mother: 

(1) Half-curved, with sutures of heavy silk. 

(2) Full-curved, with fine silk. 

(3) Usual for peritoneum. 

(c) Accessories for Mother: 

(1) Stout Esmarch rubber tourniquet. 

(2) Placenta basin. 

(3) Large floor basins—copious drainage of 

amniotic fluid. 

(4) Hot saline constant. 

(5) Adhesive. 

{d) Sterile Goods for Mother: 

(1) Small sponges, many—tape sponges, many. 

(2) Gauze to wall off. 

(3) Dressings. 

(c) Notes: 

Be prepared for hysterectomy or ligation of fal¬ 
lopian tubes (when legally indicated). 

(a) Instruments for Infant: Extra physician’s and 
nurse’s sets. Cord instruments. 


294 


THE OPERATING ROOM 


Accessories for Infant: 

( 1 ) 


Fig. 46.—Hernia 
knife. 


Reception blanket and bas¬ 
ket. 

(2) Hot and cold tubs. 

(3) Eye solutions. 

(4) Hot-water bottle. 

(5) Pulmotor. 

(6) Oxygen tank and intranasal 

catheter. 

(c) Sterile Goods for Infant: 

Cord tape and binder. 
Blow-outs. 

Mouth-wipes. 

Herniotomy. —Regarded as equally im¬ 
portant as bone-plating in rig- 
idity^ of asepsis. 

(a) Instruments: 

Dissecting set. 

Hernia knife (Fig. 46). 

2 sharp four-pronged retractors. 
2 blunt hooks. 

Artery clamps. 

Aneurysm needle. 

Kocher sound. 

Blunt dissector. 

Needle-holder. 

Needles. 


(b) Needles: 

(1) Medium-sized, sharp, half-curved with 

kangaroo tendon for deepest work (split 
sinew of tail of kangaroo)—expensive 
—keeps tensile strength throughout ster¬ 
ilization. 

(2) For sac, plain catgut No. 2 in medium¬ 

sized, full-curved needle. 

(3) For skin, silk or silk gut. 

(4) Ligatures of catgut Nos. 2 and 3 plain. 











LISTS OF INSTRUMENTS FOR OPERATIONS 


295 


(c) Accessories: 

(1) Rubber tissue or oiled silk to protect 

dressing. 

(2) Spica bandage, 6 inches: 

(а) Gauze, 

(б) Muslin. 

With oiled silk cuffs and adhesive for inguinal 
and femoral. 

(3) Hot saline. 

(4) Sand-bags are used for immobilization in¬ 

stead of spica. 

(d) Sterile Goods: 

(1) Towels, tape sponges, large gauze fluffs, 

small sponges. 

(2) A piece of sterile tape, 10 inches long, to 

slip under the cord as a retractor. 
Nephrectomy (Lumbar Route), Nephrotomy: 

(a) Instruments (cannot be placed on this laparotomy 

sheet): 

Dissecting set. 

Ligature carrier. 

Clamps. 

Aspirating syringe and needles (longest and 
largest). 

Sponge-holders. 

Set for rib resection (costotome, bone hook, 
periosteal elevator). 

Needle-holder. 

Needles. 

Towel clamps. 

( b ) Needles: 

(1) Heavy full-curved needles with silkworm- 

gut for outer wound. 

(2) Catgut No. 2 plain for skin. 

(3) Chromic gut No. 2 for muscles. 

(4) Long, sharp, full-curved needles with cat¬ 

gut No. 3 plain. 


296 THE OPERATING ROOM 

(5) Small, half-curved needles for pelvis of 

kidney, with plain catgut No. 2. 

(6) Ligatures of heavy twisted silk, or plain 

catgut No. 4, rubber. 

(c) Accessories: 

(1) Kidney bag—inflated, diseased kidney the 

higher—bag under loin of sick side. 

(2) Pillow—arms in comfortable position, to 

prevent paralysis—patient on abdomen. 
Nurses should he put in this position 
themselves to get fine details. 

(3) Footstools for all participants. 

{d) Sterile Goods: Compresses, 4 x 16 inches, and 
from four to eight thicknesses. Usual 
sponges, gauze to wall off, etc., gowns, 
% towels, etc. 

(e) Drains: 

(1) 2 red rubber drainage-tubes, i x 8 inches, 

with safety-pins. 

(2) Narrow gauze strips. 

(/) Notes: 

(1) To “deliver” the kidney means to bring it 

out through the cut with a “gush.” 

(2) Be sure that the operation is on the sick 

kidney. 

Curetage —simple model for all lithotomy work. (For 
legal data see chapter on Superintendent.) 

(a) Instruments: 

Sims’ and weighted specula. 

2 vulsellum forceps. 

2 tenacula. 

1 small and 1 large Goodell’s dilator. 

Straight and curved scissors. 

1 dull intra-uterine curet. 

1 sharp intra-uterine curet. 

1 placenta forceps. 

3 hemostats. 

Uterine sounds and probes. 


LISTS OF INSTRUMENTS FOR OPERATIONS 


297 


Uterine dressing forceps. 

Packer. 

Sponge forceps. 

Anatomic forceps. 

Intra-uterine douche tip. 

(b) Accessories: 

(1) Kelly pad (requires very thorough disin¬ 

fection) . 

(2) Rubber tubing for douche—can, plain 

water, 120° F. 

(3) Safety-pins, T-binder. 

(4) Stirrups. 

(c) Sterile Goods: 

(1) Pads, sponges, towels, gowns, sheets, gloves. 

(2) Vaginal sheet and triangles (Fig. 30, p. 232). 

(3) 2 iodoform strips 1 inch wide—packing. 

1 iodoform strip 3 inches wide. 

Test for Patency of Fallopian Tubes (Rubin’s Technic).— 
By permission of the author of “Sterility and Conception,” 
Dr. Charles Gardner Child, Jr., these notes have been 
taken and inserted here. 

Intra-uterine injection of oxygen: 

(a) Instruments: 

Metal cannula (Keyes-Ultzmann type) perfor¬ 
ated at tip by several small apertures. 
Rubber urethral tip. 

1 tenaculum (bullet) forceps. 

1 uterine sound. 

1 dressing forceps. 

1 bivalve vaginal speculum (Graves). 

An oxygen tank connected with a water bottle 
and gage. 

Mercurial manometer. 

Fluoroscope. 

a>Ray plates for roentgenograms. 

(b) Accessories: 

Iodin, sponges. 


298 


THE OPERATING ROOM 


(c) Notes: 

Rubber stopper of oxygen bottle has three 
openings, through which pass three bent 
glass tubes. Bottle contains hot boiled 
water or mild antiseptic solution. 

(1) Glass tube leading to oxygen tank dips 

below water level. 

(2) 2 glass tubes not connected with tank dip 

1 to 2 inches, but not into water. 

(3) One of the latter is connected by rubber 

tubing to mercurial manometer and one 
to the metal cannula. 

Volume of oxygen released determined by 
separate bubbles (300 to minute)—then 
regulate to displace 200 to 250 c.c. water per 
minute. 

Maintain same rate in intra-uterine injection. 
Test for tightness of all connections. 
Trachelorrhaphy: 

(а) Instruments: 

Add to Curetage. 

2 scalpels. 

1 long pair mouse-tooth forceps. 

1 probe. 

1 grooved director. 

1 tenaculum. 

6 Ochsner and 6 Kelly clamps. 

12 hemostats. 

2 pairs sharp scissors curved on the flat. 

1 pair dissecting scissors. 

1 perineal retractor. 

Wire scissors, shield, “counterpresser,” wire 
twister. 

Needle-holder. 

Needles. 

(б) Needles: 

(1) Cervix needles with chromic gut, Nos. 

2 and 3. 


LISTS OF INSTRUMENTS FOR OPERATIONS 299 


(2) Silver wire—five sutures—metallic silver it¬ 
self is antiseptic through oxidation. 

(c) Sterile Goods: Sponges, pads, etc. 

Perineorrhaphy: 

(a) Instruments: 

Add to Trachelorrhaphy: 

Kelly’s crooks (as retractors). 

3 vulsella. 

( b ) Needles: Special perineal needles—silk gut, 

chromic gut, Nos. 2 and 3, or button, shot, or 
silver wire, and silk to carry it on account of 
severe strain during defecation. 

(c) Accessories: Antiseptic powder. 

(d) Sterile Goods: Gauze packing—plain strip, for 

vagina. 

Hemorrhoidectomy, Ligation, Local Anesthesia: 

(a) Instruments: 

Dissecting set. 

Brinkerhoff’s slide rectal speculum. 

Headlight or droplight. 

Pratt’s bivalve speculum (to deliver hemor¬ 
rhoidal tumors). 

4 Halsted curved hemostats, 5 inches (to bite 
“spurters” or pull down tumors). 

1 pair scissors, blunt, curved on the flat, 6 
inches (to dissect tumors back to their base). 
1 single-toothed tissue forceps, 7 inches (to 
remove “tabs”). 

Sponge forceps. 

(b) Ligatures: Catgut, or tank package, twisted silk, 

Size 13. 

(c) Accessories: Three 25-minim hypodermic syringes 

of 2 per cent, cocain or novocain, with 5 drops 
of adrenalin chlorid (1 :1000) added to each. 

(i d ) Sterile Goods: Sponges, wipes, rectal pads 
T-binder (for M. or F.) cotton, gauze, “whistle” 
(tampon cannula), made previously of rubber 
tubing wound with gauze and copiously lubri¬ 
cated on every layer . 


300 


THE OPERATING ROOM 


(e) Notes: Sims’ position. 

Nurse or orderly on side farthest from doctor 
holds patient’s buttocks apart, and sponges. 
Hypo, of quinin and urea hydrochlorid at ter¬ 
mination of operation. 

Hemorrhoidectomy, Clamp and Cautery: 

(a) Instruments: 

Scalpel. 

Speculum. 

Hemorrhoidal clamp. 

Mouse-tooth forceps. 

Artery forceps. 

Blunt dissecting scissors. 

Scissors curved on the flat. 

Special “screw-crusher” clamp. 

Sponge forceps. 

Needle-holder. 

Needles. 

(b) Needles: 

(1) Large surgical, with plain catgut No. 3 to 

transfix large hemorrhoids. 

(2) Straight needle for small ones. 

(3) Catgut ligatures, No. 2 plain catgut. 

(c) Accessories: 

(1) Iodoform or aristol powder. 

(2) Binders. 

(3) Vaselin or K. Y. 

(4) Soapsuds, followed by saline, for cleansing. 

(5) Rubber apron. 

(6) Cautery and 3 cautery tips. 

(d) Sterile Goods: 

(1) Towel for cautery handle—sponges. 

(2) Sponge on string to plug rectum during 

work. 

(3) Short-sleeved gown for operator—towels, 

gloves, etc. 

(4) Tampon cannula or “whistle” well lubri¬ 

cated. 


LISTS OF INSTRUMENTS FOR OPERATIONS 


301 


(e) Notes: Sims’ position. 

Prepare for certain surgeons hypo, of quinin and 
urea at termination of operation as anodyne 
when out of anesthetic. 

Operation to Relieve Fistula in Ano—Local Anesthesia: 

(a) Instruments: 

1 straight sharp-pointed scalpel. 

1 curved sharp-pointed scalpel. 

1 straight probe-pointed scalpel. 

1 curved probe-pointed scalpel. 

Probes, flexible and plated. 

Grooved directors, flexible and plated. 

1 probe-pointed grooved director. 

1 Wilm’s plated angular director. 

1 Brinkerhoff slide speculum. 

4 Halsted hemostats. 

1 single-toothed tissue forceps, 7 inches. 

1 pair scissors, sharp straight, 10 inches. 

1 pair curved sharp scissors, 10 inches. 

1 pair Allingham’s rectal fistula scissors. 

2 bone curets. 

(b) Ligatures for Bleeders. 

(c) Accessories: 3 hypo, syringes for local anesthesia 

as in Hemorrhoidectomy, ligature, local anes¬ 
thetic; also binder, lubricant, etc. 

(i d ) Sterile Goods: Gauze, cotton, pads. 

Operation to Relieve Fissure in Ano: 

(a) Instruments: 

Dissecting set. 

Rectal speculum. 

( b ) Usual accessories of rectal work. 

Circumcision: 

(a) Instruments: 

Dissecting set. 

2 Kelly clamps. 

6 retractors (small special). 

1 special circumcision clamp. 

Needle-holder. 

Needle. 


302 


THE OPERATING ROOM 


(b) Needle: Smallest round body with plain catgut 

No. 00, or silk. 

(c) Accessories: 

Sterile lubricant. 

Boric acid solutions. 

(i d ) Sterile Goods: Sterile bandage, to tie snugly out¬ 
side of first well lubricated dressing (tourniquet) 
—tip exposed—gauze. 

Internal Urethrotomy: 

(a) Instruments: 

2 or 3 urethrotomes (Maisonneuve, Otis, 
Maisonneuve-Fluhrer). 

1 straight blunt bistoury. 

1 Gouley’s beaked knife. 

Filiforms. 

Large hand syringe and catheter. 

No. 28 to 30 French steel sounds. 

(b) Accessories: 

Soap, pitcher. 

Opium suppositories. 

Boric acid, warm. 

Stirrups. 

(c) Sterile Goods: Water, sheets, towels, sponges, 

fluffs, gloves, etc. 

External Urethrotomy: 

(а) Instruments: 

Hand syringe and catheter (to fill bladder— 
walls must not be allowed to collapse). 
Tunneled sound, full-sized. 

Scalpel. 

Perineal tube No. 30 to 35 French. 

Clamps. 

Gorget, or probe-pointed director. 
Needle-holder. 

Needle. 

(б) Needle: Silk suture through perineal tube, and 

edges of wound on round-bodied needle. 


LISTS OF INSTRUMENTS FOR OPERATIONS 


303 


(c) Accessories: 

Kelly pad. 

Boric acid or saline, warm, T-binder, split (M.), 
opium suppository, bottle of bichlorid of 
mercury 1 : 1000 under bed. 

(d) Sterile Goods: Fluffs of gauze, sponges, gloves, 

gowns, towels. 

Prostatectomy, Suprapubic (enucleation for hyper¬ 
trophy of gland): 

(a) Instruments: 

Dissecting set. 

Syringe and stiff gum catheter—wash out blad¬ 
der at first and last—test for free drainage 
before closing. 

Scoop (to remove calculi). 

Artery clamp—Kelly and other strong forceps. 
Sponge forceps. 

Needle-holder. 

All stimulation sets. 

( b ) Needles: Silkworm-gut sutures, deep into recti 

muscles on round needle. No sutures in bladder. 

(c) Accessories: Hot boric acid to irrigate for hemor¬ 

rhage (only 2 mins.). 

Thermometer, all glass. 

Kelly pad and stirrups. 

( d ) Drains: Rubber tubes, f inch in diameter and 

5 inches long with large openings on sides, in 
bladder gauze wick in wound, outside of 
bladder. 

(e) Sterile Goods: Gowns, gloves, sheets, many 

sponges, triangles. 

Amputation of Leg: 

(a) Instruments: 

Dissecting set. 

1 curet. 

1 periosteum elevator. 

1 sequestrum forceps. 

1 rongeur, 


304 THE OPERATING ROOM 

1 large bone-cutting forceps. 

1 large saw. 

1 rubber tourniquet. 

1 needle holder with needles. 

1 amputation knife. 

(b) Needles, etc., as usual. 

Bone Work in Osteomyelitis: 

(а) Instruments: 

Dissecting set. 

1 mallet. 

3 chisels, assorted sizes. 

1 gouge. 

1 periosteum elevator. 

1 pair bone-cutting forceps. 

1 sequestrum forceps. 

4 rake retractors. 

1 bone curet. 

(б) Accessories as usual. 

General Addenda: 

1. Commonest needles, Martin and Mayo. 

2. Select needles carefully before operation and boil in 
gauze or perforated metal needle box—then dry and lay 
loose under towel. 

3. Trocar and cannula should be boiled together—rub¬ 
ber tube added after boiling. 

4. Cautery requires special intelligent care—always 
in commission—tips protected in soft box—smooth, pol¬ 
ished after each case. 

5. Iodized catgut must be kept in a dehydrated con¬ 
tainer, as deterioration keeps pace with the degree of 
moisture. 

6. Forty-day chromic gut is apt to cause irritation or 
“catgut indigestion” with serous exudate, sloughing of the 
knot, and fright to surgeon and patient. It may be lack 
of absorption only. 

7. Honesty is an absolute term, not relative, when ap¬ 
plied to the processes through which catgut passes in a 
nurse’s hands. 


LISTS OF INSTRUMENTS FOR OPERATIONS 


305 


8. In bone work forty-day chromic gut is a resistant 
but absorbable material. 

9. In secondary perineal repair forty-day chromic gut 
resists absorption for not more than ten to twelve days, 
hence silk gut is better. 

10. Sutures and ligatures must be covered with a dry 
sterile towel after being opened and threaded, then 
moistened swiftly before handing to the surgeon. 

11. If moistened too much, catgut loses 50 per cent, of 
its tensile strength. 

12. Do not be too generous in making catgut ready. 

13. Formol, trioxymethylene, and paraform, generated 
in special cabinets, are good for genito-urinary instru¬ 
ments; but it is more essential to have them smooth, 
bright, and to handle them gently than to sterilize them 
for an already infected area. 

14. Dip them in sterile boric acid as a lubricant. 

15. Sounds are in bags with sections (as flat silver is 
kept). 

16. Wash with soap and water, dry on sterile gauze, 
wet with alcohol, and let it burn off, or boil in 2 per cent, 
washing soda solution or plain water; cool with cold 
sterile water. 

17. The tunnel in a sound must be cleaned well with a 
stiff nail-brush, soap, and water. 

18. Hard-rubber tubes must not be boiled. 

19. Olivary bougies are not boiled—lay away straight, 
in compartments. 

20. Whalebone must be kept straight; oil, keep dry in 
metal box, no boiling. 

21. Blade of urethrotome never heated—set in alcohol. 

22. Woven catheters—cleanse with hot water and soap 
—cool and dry—lay away straight and separate. 

23. Soft catheters—buy the best—test for elasticity— 
discard when lifeless (they may come apart in the patient). 

24. Ureteral catheters with stylets—wash in soap and 
water—let water drain through (mistake might make a 
diagnosis with fatal significance to wrong patient)— 

20 


306 


THE OPERATING ROOM 


hang in formalin cabinet—wet with sterile boric acid 
before using. 

25. Cystoscopes—wash—run alcohol through—dry— 
hang in formalin cabinet. Dip in cool boric acid before 
using. 

26. Lubrication by lubrichondrin is most safe and 
smooth. Olive oil can be syringed into cavities. 

Emergency Sets: 

These are put up and labeled in order to hasten relief 
for a patient, in night emergencies, or other instances in 
which the operating-room staff is at its minimum. They 
contain sheets, towels, instruments, et al., and shorten 
splendidly the time and labor required. They meet the 
demand for: 

(1) Secondary hemorrhage from tonsils or other nose 

and throat work. 

(2) Tracheotomy. 

(3) Ear cases, excision of part of jugular vein in throm¬ 

bosis of lateral sinus. 

(4) Transfusion. 

(5) Intravenous infusion (bottles included). 

(6) Hypodermoclysis. 

(7) Aspiration. 

(8) Evacuation of free fluid in abdomen, following 

ruptured gastric ulcer or appendix, or of a cyst. 


CHAPTER XVIII 


MINOR WORK IN THE OPERATING ROOM 

Intravenous Infusion—Gravity Method: 

(a) Instruments (same as for hypodermoclysis)—put 

away sterile: 

Scalpel, freely curved edge. 

Grooved director. 

Probe. 

Forceps, plain. 

Forceps, mouse-tooth (not on vein). 

Artery clamps. 

Curved scissors. 

Cannula of silver only. 

Needle-holder. 

Needle—curved or straight Hagedorn, with 
plain catgut No. 1 in tube. 

Glass connecting tube. 

Fine rubber tubing (never cut a catheter to fit 
a cannula). 

To put these up, boil, dry with aseptic precautions, and 
label, so that they may be used also, if necessary, for 
'phlebotomy. Nurse putting them up signs label. Dry 
dressing sterilizer might rust instruments. 

(b) Jar and remainder of equipment —as for hypoder¬ 

moclysis—put away sterile. 

Irrigating jar, tubing and tape—numbering 0 
at the top. 

Cut-off. 

Dairy thermometer (all glass) in solution. 
Infusion thermometer in tubing at proximal end 
(showing temperature at delivery). 

2 pieces of large rubber tubing (one long, one 
short). 


307 


308 


THE OPERATING ROOM 


These bundles must always be kept in the same place, 
to avoid confusion in emergencies. 

(c) Accessories: 

Infusion stand. 

Table for the arm. 

Tourniquet (Esmarch). 

Sponge pail. 

Asbestos mat. 

Sponge stick. 

(d) Sterile Goods: Towels, flat gauze sponges, 2-inch 

gauze bandage, caps, gloves, aristol, hot and 
cold sterile water and pitcher, saline flasks, 
iodin 2J per cent. (J tincture, f alcohol). 
These can be assembled on any well-managed 
ward. 

Remarks. —Intravenous infusions are not always man¬ 
aged successfully. There are never any two same persons 
present in the various groups giving it in any hospital. 
People do not work smoothly together the first time, par¬ 
ticularly in such a crisis. The remedy is DRILL BE¬ 
FOREHAND. The nurse when on probation, giving 
baths, is preparing for this, by closely observing the size 
and position of the superficial blood-vessels, in arm or 
ankle. There have been so many unhappy traditions 
about infusion sets, aspirators, and cauteries that some¬ 
times a doctor evinces mild surprise when an infusion 
goes well. 

There should be two sets for the smallest hospital, (a) 
In case two patients needed it, or ( b ) if parts are lost, or 
(c) if parts are being replated, or ( d ) if a patient is in isola¬ 
tion. They should be opened at regular intervals to see 
that all is in order and rustless, then resterilized. This 
is not a waste of energy. The instruments are to be of the 
best, not discards. 

The old vexed question of temperature has been solved 
by the infusion thermometer, registering from 90° to 
104° F., fixed inside a glass cylinder as a connecting tube. 
This is inserted in the pipe near the wound, or point of 


MINOR WORK IN THE OPERATING ROOM 


309 


delivery. The solution in the tank is usually kept at 
about 120° F., so that when it passes through 4 feet of 
tubing, cooled by the surrounding air (which is 70° F.), 
it will be delivered at 100° F. Too high a temperature 
causes sloughing. 

The jar shaped like an inverted cone is most satis¬ 
factory, and the speed can be controlled by pinching the 
tube, to prevent acute dilatation of the heart. Do not 
be tempted to raise the jar high, so as to get through 
quickly. The bottom of the jar is one foot only above the 
patient’s heart. 

Nursing .—The pulse, respiration, skin, perspiration, 
color, finger-tips, body temperature (hand), faculties 
must be carefully scrutinized. When showing sound re¬ 
turn to normal the treatment is stopped. 



Fig. ‘47.—Meinecke infusion and irrigating thermometer. 


Arithmetic .—The nurse must give the statements about 
the quantity of saline thrown in from time to time. 
When about to pour in, pinch the tube and note how much 
is in the jar. Then pour in and note how much. If it 
were standing at 750 c.c. (near bottom), and we raised, 
it to 150 c.c. (near top) we really added 600 c.c. (750 — 
150). Add new before the first gets below the lowest 
mark: 

(a) So that we can estimate it exactly. 

(h) To let no air into the vein. 

Adding .—When putting solutions in jar, cool first, then 
hot. When wishing to heat, add hotter saline very slowly , 
watching upper thermometer. Pinch the tube till these 
temperatures are adjusted. 

Infusions are given after a hemorrhage, after the bleed¬ 
ing vessels have been tied off. It is exactly like priming 
a pump that has gone dry. Normal saline contains as 




310 


THE OPERATING ROOM 


much salt as the blood, and if thrown in to prime the 
heart and give it something to do, the patient can manu¬ 
facture more blood in a day or two. (See Anastomosis in 
any Anatomy text-book.) 

The tourniquet is put on the upper third of the hu¬ 
merus, between the heart and the seat of incision. The 
usual incision is in the median basilic vein. 

Saline for infusions is made up triple strength, that is, 
3 drams to 1 pint, so that the very hot salt may be 
the proper strength when diluted with cold sterile 
water. It requires less space for storage also. It must be 
labeled “infusions—triple strength,” to avoid mistakes, 
in an age of hurry and insincerity. Nurses desiring this 
for ward use must not help themselves. An operating- 
room nurse gives it out. At night the night supervisor 
is responsible, reporting where the goods went. 

Hypodermoclysis: 

(a) Instruments: Put up sterile and labeled: 

Two needles with stylets (all in good condition, 
dried, lubricated, sizes assorted). 

Two pieces of fine rubber tubing to fit them. 

One glass Y. 

(b) Jar , as in Intravenous Infusion. 

(c) Accessories , as in Intravenous Infusion, with col¬ 

lodion and cotton. 

Remarks: 

(1) Do not put hot flasks on glass table tops. 

(2) Set up a sterile table with disinfected 

dressing forceps to handle goods. 

(3) When pouring into the jar, hold the 

pitcher an inch away from it. 

(4) Nurse prepares patient: 

Arms above head, 

Gown drawn up to chin and tucked 
tightly under shoulders, 

Face shaded by towel, 

Sterile towels across chest and abdomen 
above and below nipple line. 


MINOR WORK IN THE OPERATING ROOM 


311 


(5) Nurse manipulates the cut-off till tem¬ 

perature is 100° to 102° F. 

(6) Nurse notes amounts, replenishes, takes 

pulse, scrutinizes patient. 

(7) Usual amount 1000 to 1500 c.c. 

(8) Surgeon massages fluid into remoter 

tissues. 

(9) Packages must be put up by operating- 

room nurses only—ward nurse simply 

boils and cleans them. 

(10) Boiling in a towel keeps scum off. 

INJECTION OF BLOOD-SERUM 

In certain conditions of (1) hemorrhages of the new¬ 
born, (2) traumatic hemorrhages, (3) hemorrhages after 
operations, and (4) purpura hsemorrhagica (early) the 
loss to the general circulation is sometimes restored by the 
injection of blood-serum. As in transfusion, the blood 
of a very near relative by consanguinity—that is, one’s 
own parent or a descendant of the same parents as one’s 
self—must be obtained. For a’newborn infant the father, 
and for a newly delivered woman her father, mother, 
brother, or sister. The blood from the donor is with¬ 
drawn, set in the ice-box in a sterile open-mouthed vessel, 
but covered, to permit taking out the clots easily after 
they form, yet let nothing unclean drop in. In twenty- 
four hours, when the coagulable matter has collected into 
one clot, the serum, now absolutely clear and slightly 
heated to body temperature by standing in tepid water, 
is injected by a large ground-glass syringe in doses of 
15 to 25 c.c. in the patient’s buttocks. As a rule the 
second treatment is the last. In all these cases the donor 
shows marked effects: (a) Bluish patches.under the eyes, 
which are sunken; (5) general lassitude; (c) great disturb¬ 
ance of the heat centers, heat sensations rapidly and 
irregularly alternating with cold, showing that he must be 
put to bed until his circulation is readjusted. The injec¬ 
tion is performed with strict asepsis. 


312 


THE OPERATING ROOM 


Transfusion.—The method of transfusing has changed 
greatly recently, and the scope of its use broadened. 
Needles reduce the danger of infection, a vital point, as 
blood is a fine medium for the growth of bacteria. There 
are two great difficulties in the way of transfusion: 

(1) Any of the blood may clot rapidly and cause a 

thrombus. 

(2) It is hard to find compatible blood. 

Professional donors are listed in large cities, each with 

his serum typed. “One whose blood will suit all cases is 
called a universal donor.” Citrate has been used as an 
anticoagulant (to prevent clotting), but its chemical action 
destroyed some qualities of the blood, and caused such 
reactions as malaise and chills in the patient. Brines 
now uses whole blood, unmodified, with better results. 

Nurses must be careful in the use of this term, as dis¬ 
tinguished from infusion, in which 

(а) The solution is saline. 

(б) There is only one person treated. 

(c) There are no coagulation tests needed. 

Transfusion, on the other hand, transfers blood warm 
from one person to another, lying side by side. The 
accurate diagnosis of ectopic pregnancy, followed by 
aspiration of the free blood in the peritoneal cavity, and 
transfusion to the same patient has been performed suc¬ 
cessfully by a surgeon in Washington. It is indicated 
in the following cases: gastric and duodenal ulcer, typhoid, 
ectopic pregnancy, hemorrhage in tonsillectomy, advanced 
purpura hsemorrhagica, hemophilia, carbon monoxid 
poisoning. 

The patient could be killed with kindness if the blood 
of the donor (preferably a blood relation, mother, father, 
sister, brother, son, or daughter) does not correspond in 
the coagulation test. The blood of a cat, injected into a 
human being, causes death probably after the first, posi¬ 
tively after the second, by hemolysis. Vice versa, if a 
man’s blood were injected into a cat, the latter would 
die from blood destruction. 


MINOR WORK IN THE OPERATING ROOM 


313 


The Unger method is simple and quick,' affording few 
opportunities for mishaps. Patient and donor lie on 
parallel tables with a board or small table of equal height 
between them. They face each other, but are covered. 
The special Unger syringes are set on the table, and after 
the arms are punctured, the syringe to the patient is 
closed while that to the donor is filling. Then the latter 
is closed while the fluid is propelled into the vein of the 
patient. 

The amount is estimated by multiplying the number of 
cubic centimeters in one syringe by the number of times 
it is filled. This is recorded on the chart. 

The slight wound is sealed with collodion and cotton, 
so that, with the usual skin preparation, there is a mini¬ 
mum chance for infection* 

The patient’s color, lips, nails, skin, pulse and respira¬ 
tion must be very closely watched during this brilliant 
and showy performance. The donor, being excited and 
healthy, sometimes has such a blood-pressure, that the 
syringe piston is pushed back by it. 

Administration of Salvarsan or Neosalvarsan—Grav¬ 
ity method: 

(a) Instruments and glass , etc., to be sterilized: 

Straight artery clamp. 

2 needles—special—shortest, simplest are best 
—with stylets. 

2 cylindrical graduated tanks, holding each 
300 c.c., with spouts. 

2 long rubber tubes—from tanks. 

Nickel-plated “dog” with 3 mouths for attach¬ 
ments (2 cut-offs with switch). 

2 glass connecting -tubes (windows) tapering 
points. 

2 fine rubber tubes to fit “dog.” 

1 fine rubber tube to vein with window and 
metal collar, threadless, on which needle fits. 

1 glass graduate to mix saline and salvarsan. 

1 glass stirring rod. 


314 


THE OPERATING ROOM 


(6) Supplies: 

Tablets of salt (measure) for salt solution. 

Ampules of salvarsan in correct dosage (or 
neo-salvarsan). 

Distilled water. 

Pitcher. 

Sterile towels, sponges. Esmarch bandage, al¬ 
cohol, cotton, iodin and collodion, tripod to 
elevate tanks. 

(c) Method: 

The nurse boils the set A in a pan lined with a 
towel, stuffing the cylinders with cotton so as 
to keep them free from scum. 

She boils the distilled water in pitcher (measur¬ 
ing water with graduate), and cools it to 
room temperature. The physician dissolves 
the salt tablets in distilled water in sterile 
graduate, by help of glass rod, and with the 
“dog” shut, fills the saline tank up to about 
60 c.c. The nurse then disconnects this 
tube, pinches it, raises it to the level of the 
surface of the solution in the tank, to throw 
back the air—and repeats this twice more, 
so as to be sure there is no air. 

The physician, meanwhile, breaks the ampule 
of the drug with file, empties the contents 
into the graduate with the balance of the 
boiled water, dissolves thoroughly, and pours 
into the second tank. The nurse watches 
that the “dog” is shut while he pours in, then 
she expels the air (three lifts) as before. 
Then she expels the drug from the third or 
lowest tube and sees that the needles are 
patent. 

The “dog” should have a mark on the outlet 
(leading to the vein) and always be used the 
same way. 

To let the saline into the vein, the first step is 


MINOR WORK IN THE OPERATING ROOM 


315 


to throw the lever over between the saline 
tube and the outlet. This must be instan¬ 
taneous. The nurse has to work fast, hence 
she needs frequent rehearsals. The doctor 
sterilizes the skin over a likely vein, with 
iodin, and then clears the field with alcohol, 
drying it well. Then he applies a tourniquet, 
which the nurse clamps. Then he punctures, 
and the nurse has the flow of saline already 
at the mouth of the tube, which he connects 
on the needle while she instantly releases the 
tourniquet cautiously, so as not to get it 
smeared with blood. Then she marks the 
amount of saline—raises the standard, and 
after 5 c.c. are given, throws the lever over to 
the other side, and watches the salvarsan 
disappear from tank, tube, window, etc. 
When it is due at the “dog,” she switches 
back to saline to leave none of the irritant 
drug near the wound. When there are about 
5 c.c. again given, she pinches the tube, the 
doctor withdraws the needle, and seals the 
opening. If the needle is kept out of the pan, 
those things not contaminated need not be 
boiled to put away. The patient tastes the 
drug in forty-five seconds. Towels must be 
boiled before sending to the laundry. Giving 
saline first shows that the needle is in the 
vein, and also dilutes the drug at the point 
we wish to keep free from callus or thickening 
for future punctures. The patient, if the 
stomach is empty, will have less nausea and 
malaise, though with large doses there is 
sure to be chill. If given about 5 p. m., he is 
in good condition in the morning. Specimen 
of urine examined regularly. This is so uni¬ 
versally given that private nurses should 
learn how to assist. The stage in which 


316 


THE OPERATING ROOM 


patients are should be told the nurse, the 
degree of infectiousness, the seat of exist¬ 
ing lesions. Even in the poorest clinic the 
method should have operating-room technic. 
These cases are not done in an operating 
room. 

Phlebotomy (Venesection, Blood-letting, Open and 
Closed Methods): 

(а) Instruments —Open Method: 

One scalpel. 

One scissors. 

One grooved director. 

Two mouse-tooth forceps. 

One aneurysm needle. 

Four hemostats. 

Catgut ligatures. 

Cannula (p. r. n.). 

(б) Accessories: 

Iodin and alcohol. 

2 pus basins to catch blood at wound. 
Graduate. 

Pail. 

Large rubber to protect bed. 

Bedside table (set to be convenient for opera¬ 
tor). 

Brush (wire and bristles). 

(c) Sterile Goods: Sponges, towels, gown, gloves. 

(< d ) Notes: 

(1) The degree of fibrination must be found 

by whipping the blood with a special 
brush into clotted strings, as after post¬ 
partum hemorrhage—the weight of fibers 
to total measure of blood. 

(2) Set table with aseptic precautions. 

(3) Do not let patient see blood or stains— 

reassure him—watch force and frequency 
of pulse, before, during, and after, and 
chart all data. 


MINOR WORK IN THE OPERATING ROOM 


317 


(4) Do not allow any stream to escape un¬ 

noticed below basin, thereby depleting 
the patient more than is accounted for— 
rubber tube on cannula prevents this. 

(5) This treatment is now comparatively rare, 

and used only in conjunction with accu¬ 
rate diagnostic tests with sphygmoman¬ 
ometer, etc. The doctor formerly was 
called the “leech,” when all disease was 
supposed to be curable by blood-letting, 
and living leeches were applied to suck 
out the overplus. 

Phlebotomy —Closed: 

(а) Instruments: 

Needle with stylet—rest as above. 

(б) Notes: 

(1) To relieve plethora, etc. 

(2) To obtain small amount as specimen for 

blood-culture. Pathologist has special 
technic to prepare the skin, sterilize the 
instruments and the containers carried 
to the laboratory—very elaborate— 
should be posted in nurses’ work-rooms; 
and arranged to suit him. 

(3) Our desire for asepsis is to prevent bacteria 

from entering the patient. 

His desire is to prevent any but the bac¬ 
teria already supposed to be in the blood¬ 
stream to enter the specimen. He is 
assisting the surgeon to make a diagnosis 
for some febrile or septic condition. 
Cystoscopy —Excessive precaution not to get specimens 
mixed (major in importance, but not requiring 
general anesthesia): 

(a) Instruments: 

Cystoscope. 

Catheter (urethral). 

Catheters (2 ureteral) and stylets. 


318 


THE OPERATING ROOM 


Sponge sticks. 

2 small glasses. 

1 glass syringe. 

2 test-tubes marked L. and R. 

3 sterile bottles (4 oz.—bladder, right and left 
ureters) marked B. L. R. 

Toothpick swabs to anesthetize meatus with 
cocain. (See chapter on Dressings.) 
Hypodermic syringe and needle for phenol- 
sulphonaphthalein. 

(6) Accessories: 

Alcohol or iodin for skin for hypo. 

Tincture of green soap and water, to scrub. 

K. Y. lubricant. 

10 per cent, sodium hydroxid. 

Cocain crystals in charts—cocain, 4 per cent., 
to be made up. 

Ampule of phenolsulphonaphthalein and file. 
Clock to time action of hypo. 

Stirrups. 

Floor basin. 

Stools for operator and anesthetist. 

(c) Sterile Goods: 

Cotton balls, gown, sponges, triangles, vaginal 
sheet, towels. 

Basin of bichlorid 1 : 3000. 

Basin of formalin, 4 per cent.—or carbolic acid, 
5 per cent., for instruments. 

Basin of sterile water to rinse. 

Pitcher of sterile water to irrigate bladder, with 
tubing and funnel or syringe. 

(d) Notes: 

(1) Patient is conscious—conversation and 

behavior should be more than ever 
ethical. 

(2) Phenolsulphonaphthalein is given to show 

what length of time is required by the 
affected kidney to throw off anything, 


MINOR WORK IN THE OPERATING ROOM 


319 


i. e., to function. A normal kidney 
throws off the colored urine in about one 
hour. 

Lumbar Puncture (diagnostic test—relief of cerebral 
pressure), injection of medication or serum: 

(a) Instruments: 

Lumbar puncture needles, special design, as¬ 
sorted sizes, with beveled stylet and an eye 
| inch above the point. 

Sterile 2-ounce glass. 

Forceps. 

Sterile glass graduate to contain the first flow 
of fluid (may be a small one). 

Sterile glass graduate (large) to send whole 
specimen to laboratory. 

( b ) Accessories: Rubber sheet, pus basin, iodin, col¬ 

lodion, table. 

(c) Sterile Goods: Cotton, sponges, towels, gown, 

sheets. 

(d) Notes: 

(1) This test is made, with operating-room 

technic, on the ward. 

(2) It is for cerebrospinal or tubercular men¬ 

ingitis, and other diseases occurring in 
the cord. 

(3) The patient must not be infected with 

more than he already has to fight. 

(4) His specimen must not be contaminated: 

(1) To show some disease he has not. 

(2) To injure patients inoculated with 

antimeningitic ( et . al.) serum 
made in the big laboratories for 
epidemics. 

(5) The lumbar vertebrae are bowed out, by 

bringing the knees and chin of the patient 
together. 

(6) The area is painted with iodin, landmarks 

taken, and the needle inserted. 


320 


THE OPERATING ROOM 


(7) Unfortunately for the mental state of pa¬ 
tients not unconscious with these dis¬ 
eases, there is no suitable local anes¬ 
thetic. Those who recover recount how 
harrowing it is, hence, though they may 
be rigid and speechless, nurses and doc¬ 
tors must never indulge in cold, indiffer¬ 
ent conversation or badinage. 

Injection of Serum or Anesthetic in Spinal Cord (Sto- 
vain): 

(a) Instruments: 

Add to Lumbar Puncture: 

(1) Special glass (gravity method) and tube— 

20 c.c.—graduated, taper point. 

(2) Needle of above—all fit. 

(3) Sterile glass into which to pour stovain 

from ampule, thence into (1). 

(b) Serum or anesthetic: Standing in warm jacket of 

bichlorid of mercury 1 : 3000 at 100° F. 

(c) Notes: 

(1) Patient has less malaise and other reactions 

of uncomfortable sort if injected fluid is 
at body temperature (not above, as it 
will thicken). 

(2) No air enters. 

(3) No force is employed—merely tapping, or, 

as in maple trees, fluid is let run by 
gravity, never propelled by a piston suc¬ 
tion. 

(4) Stovain is a chemical substance, innocuous 

to a normal heart or kidneys, hence an 
alternative to general anesthesia. 

(5) Stovain is followed by operation (often 

major), hence patient receives it sitting 
on the table. 

(6) Strip him to waist of loose operating-room 

garb, let lean forward, resting his arms 
on the shoulders of a short orderly, 


MINOR WORK IN THE OPERATING ROOM 


321 


standing close. Spinal fluid is drawn off, 
and may be thrown away, on word of 
surgeon, at once. Tube for stovain is 
connected and held very low, to show 
presence of spinal fluid (and expel air), 
then the drug is added, before raising it 
to let it run in. Patient’s eyes covered, 
his sensation is now tested, from the toes 
up to the site for the wound. When 
complete anesthesia up to the desired 
point is obtained, he is laid on the table, 
and the operation is begun. Some pa¬ 
tients have died after this anesthetic, 
while for others it has seemed ideal. The 
anesthetic must not be blamed for the 
death when it may have been the 
operation. 

Artificial Respiration: 

This is positively the duty of the physician, but in case 
he is not to be found, or has been incapacitated in any 
way, a nurse should know how to perform it, just as it is 
done by the Life Saving Corps or by gymnasium in¬ 
structors. 

The Sylvester method is very satisfactory because it 
can be comprehended by others than physicians. 

General Rules: 

I. Never give up hope; keep up the treatment for at 
least ninety minutes. 

II. Consider the patient alive at the start.- 

III. Carry out the treatment where the patient is. 

IV. See that there is no obstruction in the nose or 
throat. 

V. Do not get excited and do not give too rapidly. 

VI. Elevate the patient’s shoulders about 4 inches. 

VII. Clamp the tongue, and let another assistant 
draw it forward with each expiration, and not let it drop 
back, ever so slightly, with each inspiration, impeding it. 

VIII. Stand or kneel far enough above the patient to 
21 


322 


THE OPERATING ROOM 


have good purchase when pressing downward behind 
his head. 

IX. Make the (inward and outward) respirations for 
an adult 16 to the minute—that is, 3f seconds each— 
two seconds for the inspiration and almost two seconds for 
the expiration. 

X. (a) Grasp him by the forearms, half-way between 
elbows and wrists, and draw up his arms out and over his 
head steadily until the hands touch the table, floor, or 
ground behind his head. Hold them there for two sec¬ 
onds. This motion expands the chest by drawing up the 
ribs; air may enter. Two seconds’ halt allows it plenty 
of time to fill the lungs completely. (6) Reverse that 
movement. Carry the arms downward until they rest 
against the sides of the chest, bringing the forearms in a 
little on top, pressing them firmly downward and inward 
against the chest for one second. Listen for the sound of 
air entering and leaving. If not heard, the work has 
been done incorrectly. 

Other Means of Resuscitation: 

(1) Cesarean section: Newborn infant: 

(a) Hot tubs, 110° F. } . , 

Cold tubs, 70° F. | alternate sousing. 

( b ) Throwing up in air—extended at full length 

—one hand at back of neck, ofie hand at 
buttocks. 

Bringing down with force—collapsing, 
drawing together—to empty lungs of 
mucus (like shutting a concertina). 

(c) Blowing air into lungs, through sterile 

gauze rolls, moving up 6 inches of the 
roll each time. 

(d) Suction apparatus. 

(e) Dilation of rectum by speculum or fingers. 

(2) Sundry other conditions. 

Pulmotor. 

Administration of Radium.—This powerful, costly, 
minute, dangerous substance requires prolonged study, 


MINOR WORK IN THE OPERATING ROOM 


323 


extreme care, and vigilance. It should be kept under 
liable lock and key. Its power is measured as “emana¬ 
tions” in units called “mache” units, so many thousand 
per minute. A tiny portion is laid in a hollow cylinder 
and held in the vicinity of the lesion for which its use is 
prescribed, by the operator, for a specified time, then 
withdrawn. The cleansing, position, and draping of the 
patient are the same as for a corresponding operation. The 
work and observations of the surgeon are charted. The 
special technic of radium is more than the work of a life¬ 
time and must be partially acquired by practice with 
experts. Visit reliable radium institutes, recognized by 
the great medical academies. 

Forms of Stimulation in the Operating Room (not pre¬ 
viously given): 

(a) Coffee enema: 

Black Coffee: Take 1 cup ground coffee and 
1 cup cold water. Bring to boil rapidly, clear 
with a dash of cold water—reduce to 110° 
F., and give, with warmed tube, funnel, etc. 

(b) Saline: Saline 5iv and whisky or brandy §j, 

at 100° F. 

(c) Elevation of feet. 

( d ) Heat in all forms. 

(e) Hypodermic injection (see Hypodermic Injection). 

Intravenous Therapy.—This form of administration of 

medication enjoyed a much greater fervor at one time 
than now, though used yet for some types of disease 
legitimately. The technic is as for salvarsan. There is a 
danger from fads, but when proper to give it, the operating 
room should send one of its nurses to the ward if there are 
none there with that training previously. 

Treatment for Hemorrhage.—Primary. Secondary. 
In “open” hemorrhage, where it can be controlled by 
ligation, vessels are immediately tied off. Do not stimulate 
the force of the pulse while vessels are open. Treat for 
collapse, otherwise (air, rest, heat, elevation, pressure). 
Primary hemorrhage in the operating room falls to the 


324 


THE OPERATING ROOM 


care of the circulating nurse, hence she must be well 
drilled in speedily doing the right thing. Pressure will 
include 

Digital, 

Tourniquet, 

Binder, 

Tonsil clamp when indicated (boil). 

Elevation must include knowledge of the circulatory 
system. Styptics include 

Very hot water, or sponges, 

Cold, 

Silver nitrate, 

Cautery, 

Adrenalin, 

Stypticin. 

The operation may stop and more ether be given. 

Secondary hemorrhage occurs after the operation, and 
must be watched for after all cases, particularly tonsils, 
vaginal hysterectomy, and any form of childbirth. Always 
expect it. Never let it surprise you. Always have in¬ 
struments and packing ready for every type. The surgeon 
will probably order morphin, if not previously given within 
too short a period. His work is ligation, cauterization, and 
packing, during which he expects the nurse to proceed 
automatically with all other measures. The history of 
every patient needing surgical care must be taken relative 
to hemophilia. Rehearsal of all these nursing procedures, 
with a dummy, at a snappy signal, is very necessary to 
avoid confusion, and save steps, making every act tell. 

Hypodermic Injection: 

Simple, aseptic, efficient. 

(а) Required: Luer syringe and slip-on needle—fre¬ 
quently tested and inspected—sponge stick when iodin 

■ is used—cotton balls for alcohol—matches or pilot light— 
gas—ampule with file—liquid drug—tablets—basin to 
boil syringe—spoon—stylet in needle. 

(б) Method: After boiling, draw up barrel of boiled 
water and expel all but 20 minims. Expel this into spoon 


MINOR WORK IN THE OPERATING ROOM 


325 


—drop tablet into spoon and stir with point of syringe 
till clear—draw up into barrel—slip needle on without 
touching shank—expel air. Carry to bedside on tray, 
syringe needle resting on sterile cotton—skin preparation 
—clean skin vigorously, pinch—hold hypo, like a pen, at 
45 degrees to arm—inject—withdraw, loosen hold—stop 
with cotton—rub upward and retire. 

(c) Clean-up: Rinse barrel, dry—boil needle with 
stylet—dry thoroughly—put away in place. 

Abdominal Paracentesis: 

(a) Instruments: 

Trocar and stylet (beveled), suitable size. 
Sponge stick. 

( b ) Accessories: Rubber, pail, pus basin, graduate 

(very large tub needed at times)—collodion— 
iodin. 

(c) Sterile Goods: Cotton, sponges, towels. 

(d) Note: 

(1) This has to be done so frequently usually 

that great care must be taken not to 
injure the tissues. 

(2) Specimen to laboratory only if ordered— 

not likely. 

(3) No particles of broken glass from ampule 

should be in drug. 

(4) Do not boil the drugs. 

(5) Mercury salicylate in oil must be heated 

to blood heat only in a second cup, then 
shaken, before drawing into barrel. 

(6) After oils the syringe must be thoroughly 

cleaned with soap and water. A small 
wire and bristle brush (for drinking 
tubes) is excellent for -this purpose (and 
to clean inner tracheotomy tubes). 

(7) The needle is slipped on, and then dipped 

in to the ampule which must be held by 
another person, and the contents drawn 
up. To emty into spoon is impossipble. 


326 


THE OPERATING ROOM 


Avoid a large number of steps in any 
such, process. 

(8) With liquid medications, the requisite 

amount can be approximated and 
dropped into the boiled spoon, drawn 
up, air expelled, and measured. 

(9) With stock medications of more or less 

than the dose ordered, the problem 
must be solved on paper and o. k.’d by 
a supervisor before giving. (See chap¬ 
ter on Formulae and Directions.) 

(10) Doctors and dentists have quick, simple, 
emergency technic which should be 
studied by nurses appreciatively. 


CHAPTER XIX 


RELATIONS BETWEEN THE SUPERINTENDENT 
AND THE OPERATING ROOM 

To place anyone in a position higher than that of 
Directress of Nurses in a small hundred-or-so-bed hospital 
is a ticklish thing to do, since it infers finding one with 
more executive ability, power to please justly, and weight 
of judgment. Usually the best type has been a woman 
superintendent with nurse training, who has developed 
executive power outside the class-room, and to whom the 
public business of the institution makes a strong appeal. 
These women have been drawn out of the class-room, 
rather than rushing out and demanding higher rank. The 
narrow cramped life of a small institution will never 
appeal to a man of strong capabilities or the qualities of 
leadership, and if he has not those qualities, the position 
of business manager or financial assistant might better 
be subordinated to that of Directress of Nurses (or as 
some European hospitals name their steward “Ekonome”), 
who heads the nursing department, which is the primary 
function of all hospitals, especially as the other could 
really be carried on in a separate building or down town. 
Hence, in the field of this text-book, the term “superin¬ 
tendent of the hospital” infers a woman graduate nurse. 

The first quality she must possess in relation to all 
departments, especially the one of which this is written, 
is to be ethical—a quality not so much in evidence 
as necessary, alas! Problems arise, in booking cases for 
the use of the room, as to the type of surgery, the hours 
required, where some surgeon appears to violate a staff 
rule. When such booking is made in the office of the 
Superintendent (as distinguished from the Directress of 
Nurses) she should confer with the Directress thereon, 

327 


328 


THE OPERATING ROOM 


who knows the limitations of the operating room, and 
whose other departments are greatly affected by rushing 
aid to it. There is no occasion for, or honorable, success¬ 
ful administration in, talking to under officers of the 
training-school. They become egotistical, and can easily 
develop into an institutional menace. The operating 
room cannot live by itself alone, and its supervisor must 
lean hard and often on the Directress, hence the Super¬ 
intendent must confine all her dealings to the latter, and 
keep her fully posted. There is nothing more frequent or 
more deadly insidious, than the avoidance of the training- 
school office in all matters where graduate staff nurses or 
pupil nurses are concerned, by either surgeons or Super¬ 
intendent. Concentration of authority in this office 
avoids embarrassment, friction, and waste of time. The 
Superintendent builds her ethics on her ideas of what is 
best for all her patients, according to her conscience, 
which ought to be a very live, quickened thing. The 
pay-roll for all ward workers and staff should be computed 
and administered by the Directress, who also appoints all. 

The second quality is to be judicious. Women fre¬ 
quently go by inspiration, which is usually correct, but 
many times it cannot spring forth, when they must then 
jot down what is required and reason out the step to take. 
The wisdom of others may be drawn upon. What is 
most necessary must be done first. What is needed by the 
greatest number should be bought first. That surgeon 
who succeeds in getting the ear of the Superintendent may 
induce her to buy a cautery , which he rarely and nobody 
else uses, whereas a few more artery clamps are greatly 
missed. To be judicious is not to deplete the budget by 
personal influence, but to refer such purchases to the 
proper committee composed entirely of surgeons. 

The third quality is regularity of hours on duty. To 
be lax about time creates not unjust jealousy. The 
hospital should receive a full day’s work every day that 
it is legitimate to have. Making rounds daily, at a suit¬ 
able hour to confer with heads of departments, accom- 


THE SUPERINTENDENT AND THE OPERATING ROOM 329 


panied by the Directress when suitable, as in the operating 
room, trains the workers in systematic review of their 
field before the surgeons come, or the habit of severe self¬ 
appraisal, so often confounded now with pleased self- 
praise; also, lists of repairs for steam-fitter, plumber, etc., 
should go in very early. 

Fourth, a Superintendent must be fair, impartial, al¬ 
ways weighing statements, saying nothing till sure, leaving 
no stone unturned in investigations. The swollen self- 
aggrandizement of even one member of a surgical staff in 
isolated instances, in small hospitals, unjustly crushing 
capable men at times, is often due to the machinations of 
an operating-room supervisor, or a lax Superintendent, 
who through cowardice or blindness lets it grow. The 
sale of sterile goods, gauze, cotton, saline, Dakin solution, 
is not made for the sake of the revenue, but solely as an 
emergency measure to assist some surgeon in relieving a 
patient. The patient may be black or white, far or near, 
rich or poor. The surgeon .may be a man of weight or 
not. That is not the point. Doctors are supposed to have 
offices of their own well equipped with reserves to take 
care of.all the work they undertake. It is only when there 
is an emergency happening to the surgeon himself ( e . g., 
he has his supplies in his car on his way and the car skids 
and smashes the Dakin bottle) that he should call on the 
hospital, and when it can be had nowhere else. In other 
words, the public is not contributing charitably to main¬ 
tain an institution with high salaried workers under 
undue mental strain and irregular hours, and that most 
expensive of all academic forms, a training-school, for the 
benefit of patients outside, whom it never sees. Doctors 
who are now getting calls requiring Dakin, should have 
earned their reputation by having their own office always 
well provided with pure Dakin. In estimating the cost 
of goods sold to the outside public, e. g., gauze, cotton, 
saline, Dakin, one must refer back to the ledger account 
for the operating room. Money is not enough to pay for 
handing operating-room supplies outside. The pupils 


330 


THE OPERATING ROOM 


have to stay overtime to make them. There may have 
been an extra heavy demand on saline and only a couple 
of Florence flasks left, and if the very surgeon who asks it 
for an outside case, had another case come in and need it 
and did not find any, he would be the most angry. It is 
a good idea to issue report of sales monthly to the medical 
board. The cost of maintaining pupils long enough in the 
operating room to receive sound training must include 
the salary of graduate nurses doing general duty on the 
ward to relieve her, and of graduate nurses as circulating 
nurses in the operating room when there is a dearth of 
pupils for it. In other words, the scarcity of pupils raises 
their cost, both when they are on this service and when 
there are none. Looking on the account appended, the 
disproportion is pitiful, and it is going to take a great deal 
of time and attention from the best brains of the country 
to make a perfect system of accounting. The proof of 
the injustice of the present system is the reluctance of 
successful though disgruntled surgeons to open their own 
institutions. The concise aim to benefit the patient is the 
only safeguard. 

The fifth quality necessary for a successful executive is 
being well informed, ready to take a leaf out of another 
fellow’s book. Text-books in medical jurisprudence and 
journals containing recent verdicts should line the shelves 
of her office. Visits for study of other systems should be 
frequent and thorough, not casual, as for a semiholiday. 
What is gleaned should be noted and reported. 

Very essential, indeed, is the training for such a job, 
gained under a capable person or as a spoke in a very large 
institution in good standing. The selection of a Superin¬ 
tendent being, of course, based on careful investigation of 
credentials, she should immediately study her hospital in 
its relation to the county, state, and nation, and help make 
it creditable through the operating department, by aid of 
the Directress and supervisors. 

Seventh, when the hospital is important enough to 
have two heads, the Superintendent should have outside 


THE SUPERINTENDENT AND THE OPERATING ROOM 331 


DR. TO 


OPERATING ROOM CR. BY 



Instruments, needles... 
Electric lighting. 


Gauze, cotton. 


Steam for disinfection 

and sterilization. 

Gas, ether, chloroform 
masks. 


Alcohol. 


Cleaning materials.... 
Supervisor’s salary.... 
Pupils’ salaries. 


Salaries of graduates 
below, on general 
duty (replace pupils). 
Infusion sets. 


Salaries of graduates in 
O. R. on general duty 
(if no pupils). 


Plaster, glass, rubber 
tubing. 


Gloves, adhesive. 

Hypodermoclysis sets.. 
x-Ray work. 


Gowns, towels, sheets, 
blankets. 


Equipment (tables) . . . 
Brushes. 


Catgut silk. 


Enamel basins. 




1924 
Jan. 1 


Operating-room fees... 

Petty sales. 

Refunds. 


contacts. The ill effects of the usual cloistered life of 
an officer in a small American hospital is felt in the one¬ 
sidedness of her views, in her ignorance of special local 
conditions which are deeply rooted in the life of the 
people, and are perhaps minimizing the usefulness of the 
one and only operating arena in the community, whereas 
by church, Red Cross, school, and club affiliations she may 
learn the values set by all the towns’ people on many 
doctors whom she does not yet know, gleaning here and 
there enough local data to maintain a fair balance inside 
the institution, which should be for all, particularly in 
surgery. 

The Superintendent should be distinguished by her 
intensive study of the institution, watching for co-opera¬ 
tion in the laundry with the strenuous needs of the operat¬ 
ing room, making expert reports on the actual wear and 
tear of materials, preventing all forms of waste, of cat¬ 
gut, alcohol or electricity, observing the faithfulness of 

































332 


THE OPERATING ROOM 


each employee, perusing the history of the hospital and 
trying to discern its lack, so that, the latter corrected, it 
may function at its maximum. She need not be, further 
than her training, different from any other high type of 
citizen, afraid of nothing, willing to move on, if she finds 
her ideals do not elicit response, wearing no man’s collar, 
and resting all her judgments on the welfare of the patient. 
She should constantly endeavor to grow mentally and in 
tolerance and sympathjq and to have true growth from 
within in the hospital. Seeking advice from a famous 
hospital consultant on knotty problems will give her a 
better perspective. 

She should look upon the operating-room supervisor 
as one does on the mechanician for a high-priced Rolls- 
Royce, whose engine has better timing gears and easier 
gearshifts than those in many other cars, on account of 
the high standard of its delivery, and should supply 
whatever is asked, when the need is mentioned and 
demonstrated, so long as it is in proportion to the means of 
the institution. 

Need it be said that the moral code of the Superin¬ 
tendent must be of the highest, adamantine caliber, 
because of the severe tests to which it is subjected, in 
helping to clarify or at least honestly present situations 
arising between various elements? If she falls short in 
any one of the numerous qualifications mentioned above, 
there may be an instant debacle, and merely to cringe in 
the presence of a blusterer or egoist may cause lasting 
damage. She is the representative of the public, the clergy, 
the teachers, all moral forces, through a moral Board, for 
a fixed period, and though the hostile or selfish may be 
present, she should speak fearlessly for the friendly or 
self-sacrificing absent ones. In this day and generation 
life is held cheap not only by its frequent destruction 
per auto but also in utero. The moral fiber of the Super¬ 
intendent, who should view her hospital and its printed 
reports as if from the outside, should be so sturdy that 
the pupils trained in such institution will be in future 


THE SUPERINTENDENT AND THE OPERATING ROOM 333 


community builders of a high order, scorning to take part 
in the insidious agencies that offset decent effort to con¬ 
serve the American race. Appended below is the safest 
guide for operating-room supervisors ever printed (cour¬ 
tesy of St. Elizabeth’s Hospital, Lafayette, Indiana, in 
Hospital Progress, October, 1922): 

SURGICAL CODE, ST. ELIZABETH’S 

Before beginning any operation in this hospital, the surgeon is 
required to state definitely to the Sister in charge of the operating 
room what operation he intends to perform. 

The following operations are inethical and may not therefore be 
performed: 

1. Operations involving the destruction of fetal life. 

Such are: 

(a) Dilatation of the os uteri during pregnancy and before the 
fetus is viable. 

( b ) Introduction of sounds, bougies, or any other substances within 
the os uteri, during pregnancy and before the fetus is viable. 

(c) Induction of labor by any means whatsoever before the fetus 
is viable. Neither eclampsia nor hyperemesis gravidarum consti¬ 
tute any exception to this rule. 

(< d ) Curetment of the uterus during pregnancy. 

(e) Craniotomy of the living child. 

(/) Operations directly attacking a living fetus in extra-uterine 
pregnancy, in the absence of material shock from hemorrhage and 
before the fetus is viable. Where operations for extra-uterine preg¬ 
nancy in the fallopian tube are performed, the rent or rupture in 
the tube must be repaired whenever possible. 

2. All operations involving the sterilization or mutilation of men 
or women, except where such follows as the indirect and undesired 
result of necessary interference for the removal of diseased structures. 

Operations specifically forbidden are: 

(a) Removal of an undiseased ovary. Whenever an operation for 
the removal of a diseased ovary is performed, enough of such organs 
must be left intact if possible as will permit the same to function. 

(b) Removal of a fallopian tube which is not so diseased as to 
require removal. 

( c ) Section of undiseased fallopian tube. 

(, d ) Operations which result in obstructing the lumen of an un¬ 
diseased fallopian tube. 

(e) Hysterectomy where the uterus is not so badly diseased as to 
require the operation. 

(/) Ventral suspensions and anterior fixations or ventrofixations 
so-called, in women of childbearing age, in the absence of proof 
positive of their necessity. 

(g) The sterilization and castration of male patients. 

The fetus may be considered viable after six calendar months. 


334 


THE OPERATING ROOM 


If the fetus is known positively to be dead, operations for emptying 
the uterus may be performed. 

The question of the presence of life, and of the necessity for the 
removal of the reproductive organs, or interfering therewith, by 
surgery or medicine, must in all cases be determined by previous 
competent consultation. 

All structures or parts of organs removed from patients must be 
sent in their entirety', at once, to the pathologist for his examination 
and report. These specimens will, after examination, be returned 
by him to the operator on request. 

When a pregnant mother dies before delivery an effort must be 
made in all cases to procure the baptism of the unborn child. (This 
has not universal application.) 

It is possible that advances in surgery and medicine may render 
permissible some of the prohibitions of this code. Until further 
notification, however, the same must be followed as outlined. 

The above rules are mandatory and the violation of any one of 
them will result in excluding the operator from the privileges of the 
hospital. 

It is not sufficient that these be reported to the Board of 
Health. It has not worked out well universally. Booking 
cases requires considerable acumen and quick thought 
and confidence in an upright board, otherwise the private 
rooms of small, struggling hospitals become the mecca of 
patients of a very shady moral hue, as well as of some 
private hospitals run only for gain. Pathologic findings 
on specimens carefully collected by an honest supervisor, 
honestly reported without collusion, will expose a de¬ 
linquent from whom privileges are at once to be with¬ 
drawn. 

When an emergency case comes in, the operating 
supervisor should be given the first report, so as to be 
completely ready in time. When an article of value is 
broken and required soon, no time should be lost in sending 
a special messenger if necessary, in person for one to re¬ 
place it. The narrowness of this life and the method of 
voluntary subscription induce some officers to haggle and 
delay over a purchase, but looking at it from the stand¬ 
point of the man in the street, if, for $2 outlay you can 
operate your machine and bring in a revenue of $150, 
spend it quickly. 

Some Superintendents keep too much aloof from this 


THE SUPERINTENDENT AND THE OPERATING ROOM 335 


branch of the service, as if it were contagion, knowing 
full well that it is the arena for friction. That is shirking, 
and leads to subterfuge and deceit in under officers. 
Others attend when favorite surgeons operate, and dom¬ 
inate the assemblage in a loud voice, forgetting technic 
and bumping against sterile tables. This is undignified, 
and weakens authority. The unobtrusive, well-timed visit 
of a silent, all-seeing officer, who conveys her support in 
a glance to a faithful staff at a trying moment is worth 
her own weight in gold to the institution. 

Buying for the operating room requires special com¬ 
mittees, familiar with types of goods, and things not to 
buy are most important in a hospital or private home. 
Nothing should be bought just because it is inexpensive. 
It may never be needed. Nothing should be bought at 
the v request of only one person; the virtues of the article 
must be demonstrated to the approval of all. Articles 
for the operating room should not be out of proportion 
to those of the rest of the hospital, whether it be ward, 
dining-room, or laundry, either in number, quality, or 
cost. Glaring colors, fads in styles, and designs of toweling 
that are not continuously uniform, so as to be known 
always instantly by sight as “0. R.,” must not be pur¬ 
chased. Cheaply made goods have inferior dyes, and 
these, in turn, not being fast, ruin more valuable gar¬ 
ments; for example, a whole set of doctors’ suits, trousers, 
and jackets were made pink by the colors running in some 
cheap new towels in one metropolitan hospital. All 
purchases should be made by or at the will and choice of 
the committee on surgical affairs. Time should be taken 
by the forelock, and samples tried out long before the 
actual need to purchase. 

These various difficulties can rarely be well met by 
one person. The Superintendent, not actually engaged 
in nursing, does not know how certain goods operate. 
The operating-room nurse knows where they fail, but 
has not time to weigh, count threads, meet several sales¬ 
men on one class of goods, or write for samples and price 


336 


THE OPERATING ROOM 


lists. A “buyer,” so-called, cannot buy on his own first¬ 
hand information. He must collect statistics from the 
house and from his own bills to satisfy an exacting super¬ 
intendent. In some cases the buyer is so busy justifying 
his own existence that he puts in an inferior class of 
goods or too small a quantity, to the hampering and 
unhappiness of the workers. Then he cheerfully asks 
for an increase of salary, to utilize the margin he made, 
where it can do the greatest good to the greatest possible 
number—Number One. 

For all hospitals the simplest solution for the problem 
of buying is to become a member of that ingenious pur¬ 
chasing body, reaching from America to China, and 
capable of buying anything from drinking straws to dicta¬ 
phones, called the Hospital Bureau of Standards and 
Supplies, which is a club consisting of representatives 
from the largest and best equipped charitable institutions 
who have joined, with a fair membership fee, to support 
the actual buyers on salary, and who can then not only 
secure goods at a big discount from the wholesale firms, 
but have no anxiety about selection or delivery. They 
place their orders at the head office of the association, 
whose buyers at once send what they wish from the 
supply houses of the wholesale dealers with whom this 
bureau has fixed yearly agreements relating to that kind 
of goods. It is really a very extensive mail-order business. 
But it is not conducted for the profit of one individual. 
Hospitals are not money-making concerns. These buyers 
must weigh all goods, taste all tea, coffee, sugar, etc., 
count the threads per inch in gauze or wool with a magni¬ 
fying glass if necessary J inspect cotton under the micro¬ 
scope, test the joints, valves, and bars in all plumbing 
apparatus, and only buy in houses whose goods meet the 
proper specifications. Goods are delivered very quickly 
and perfect satisfaction is guaranteed. This eliminates at 
least one salary in institutions of some size, and in the 
small hospital releases the Superintendent to attend to 
the real superintending, of which buying should not be 


THE SUPERINTENDENT AND THE OPERATING ROOM 337 


the only duty performed, otherwise certain basic prin¬ 
ciples must be observed in buying. Good goods produce 
efficiency in the care of the patient, but they must be 
strictly accounted for in placing, number, length of use, 
and suitability. Buying a large quantity prevents ex¬ 
pense in freight and causes a feeling of security, while 
the goods are not wearing out. The responsibility of 
caring for the stock in bulk must be placed on very few, 
not only to keep it in order, but to distribute it weekly. 
Trade names have been paid for twice over. “Hexa- 
methylenamin” is bought very cheaply and used ex¬ 
actly as “urotropin” used to be; “thymol iodid” performs 
the same duties as “aristol,” but is much cheaper. But 
a drug must not be bought and used this way until it 
responds to tests correctly. When buying certain articles 
on requisition from the operating room every feature 
must be described— e. g., a jar for saline infusion must be 
graduated to 750 c.c., beginning at the top with 0 c.c., 
or, again, the length, style, material, eyes, stylet, beveled 
tip of lumbar puncture needles must all be specified. 

Whisky and brandy should be of the best quality and 
then kept under lock and key, whether in bulk or on the 
wards. Hospital whisky, as a rule, is a joke for its uni¬ 
versal badness, unfit for both mouth and hypodermic 
medication. 

Alcohol may be bought at a very low cost in its dena¬ 
tured state if the proper forms are executed. The presi¬ 
dent of the Board of Governors must sign a bond for 
$5000 for each barrel of alcohol kept in stock continu¬ 
ously by the institution as a guarantee that its use is 
confined to surgical, nursing, and pathologic ends. Were 
any one with evil intent to drink or otherwise depart from 
the legal uses of this liquid the president would have to 
forfeit this sum. An account, therefore, is kept of the 
use of all of it, and the care of it is left to a very con¬ 
scientious official, who keeps it well safeguarded for the 
president's honor. When the liquid is being ordered an 
affidavit is taken by the Superintendent and president to 
22 


338 


THE OPERATING ROOM 


the effect that its use has been honest. For use following 
carbolic acid as a cautery, however, alcohol must be used 
in its pure, not denatured, state, on the stump of the 
appendix. 

As to catgut, if the committee on surgical affairs were 
to visit and make comparisons of the various plants or 
laboratories where it is made wholesale they would be¬ 
come impressed with the folly of trying to do it them¬ 
selves and the justness of the prices imposed. Possibly 
they could also detect differences between the materials 
and preparation of these various firms such as would 
warrant the difference in prices; at any rate, in these days 
of keen competition, when every manufacturer knows the 
secrets, initial cost, and overhead expenses of his rivals, 
it cannot be disputed that when there is five cents’ reduc¬ 
tion in the price there is five cents’ reduction in the value. 
It is not necessary to pay only for a name, but when a 
name means confidence and merit it is wise to procure 
the best. Surgeons who thoroughly identify themselves 
with the highest interests of a hospital are economic of 
catgut. Their sutures are uniform for certain purposes. 
It is then easy to buy various lengths of catgut, done up 
in separate tubes for various purposes. 

Emergency Orders.—In a crisis that could not be fore¬ 
seen one is justified in ordering by messenger, special 
delivery, parcel post, or express; but for all that can be 
foreseen freight is suitable and cheap, boat transporta¬ 
tion being again less expensive than the railroads. Large 
firms appreciate regular methodical foresighted ordering. 

Important supplies that concern the actual knack or 
handicraft of a surgeon should be bought by the com¬ 
mittee on instruments with grave deliberation, not by 
the Directress of nurses or the Superintendent who has 
never fitted them to the hollow of her hand for an hour 
in the greatest crisis of a patient’s life. 


CHAPTER XX 


DUTIES OF THE NURSE IN ORTHOPEDIC SURGERY 

Classification. — (a) Open work on bones, requiring the 
most assiduous efforts at asepsis (discussed previously). 

(6) Closed operations , showing no open wound; breaking, 
straightening, or overcorrection of deformity. 

Definitions.—Surgical Diagnosis and Instruments.— 
For deformities certain technical terms are used: 

Congenital dislocation of the hip. A deformity existing 
from birth, the head of the femur being lodged outside the 
acetabulum, with the formation of powerful adhesions. 
Frequently this occurs in both sides. 

Funnel breast. A depression of the chest walls at the 
sternum resembling the bowl of a funnel. It is like a 
shoemaker’s chest, only it may occur at any point. It 
is corrected by very strenuous exercises, not by operation, 
but must be done early to abort any hereditary predis¬ 
position to tuberculosis by increasing the child’s lung 
capacity. 

Genu valgum. Inward curving of the knee, knock- 
knee, opposite of bow-legs. 

Genu varum. Splay foot; synonym of talipes valgus , 
bow-legged; inner part of the sole rests on the ground. 

The preceding are neuter nouns and adjectives, there¬ 
fore the latter end in um. 

Hallux valgus. Displacement of the great toe toward 
the other toes. 

Hallux varus. Disposal of the great toe away from the 
other toes—displacement. 

These are masculine, therefore ending in us. 

Hip disease. Usually tuberculous and in the young. 
It lodges in the head of the femur, in the acetabulum, or 
in the synovial membrane and proper structures of the 
339 


340 


THE OPERATING ROOM 


hip-joint. The early symptoms are shufflng gait, pain 
on the inner side of the knee, pain in the hip on jarring the 
heel, deformity, shortening of the limb, suppuration, and 
formation of fistulse. 

Kyphosis. Angular curvature of the spine, the promi¬ 
nence extending posteriorly. 

Lordosis. Curvature such that the convexity points 
forward. 

Osteoclast. Instrument to break bones to correct de¬ 
formity (Fig. 48). Do not confuse with the term “osteo- 



Fig. 48.—Osteoclast (Phelps’ modification of Grattan’s). 

blast,” which means a cell found in the formation of bony 
tissue in the embryo. 

Pott’s disease. Curvature of the spine with a poste¬ 
rior projection due to spondylitis or inflammation of a 
vertebra. It is usually tuberculous. It may be high 
or low. When high, it is more quickly discoverable; 
when low, it shows up usually as a psoas abscess, the in¬ 
flamed area breaking down into pus which migrates down¬ 
ward along certain muscles toward the inguinal region. 
The symptoms of Pott’s disease are stiffness of the spinal 
column, pain on motion, tenderness on pressure, undue 









DUTIES OF NURSE IN ORTHOPEDIC SURGERY 341 


prominence of one or more spines, and a particularly 
wistful facial expression. 

Scoliosis. Lateral curvature of the spine, bending of 
the column to right or left. 

Talipes. Club-foot. 

Talipes equinus. The heel is elevated, and the weight 
is all thrown on the anterior portion of the foot, like a 
horse’s foot. 

Talipes planus. Flat-foot. 

Talipes valgus. Foot turned outward. 

Talipes varus. Foot turned inward. 

APPARATUS AND HOW IT IS USED 

Bradford Frame.—This may have to be constructed 
quickly to provide horizontal fixation in cases of children 
suffering from fractures or from tuberculosis of the spine. 
The frame itself is of bent gas-piping, from f to J inch 
thick, in a perfect oblong, 1 inch wider than the patient’s 
body at his hips, and 6 inches longer than his full stature; 
that is, in the proportion of about 1 to 5. It is covered 
by a piece of stout canvas twice its width, and laced down 
the back on the center of the side away from the child 
with eyelets and stout laces. It is arranged to leave an 
opening for the bed-pan, which, however, does not in¬ 
terfere with the tautness longitudinally, which is taken 
care of by two pairs of webbing straps at the head, and 
again at the foot. This frame is constructed to obliterate 
pain, and the child can be very comfortably carried on it. 
In spinal cases he may lie and kick all he pleases if his feet 
are warmly clad. As to bodily clothing, otherwise, when 
he is applied to the frame, he wears only undershirt and 
diaper. His warm dress is put on, last of all, over the 
jacket of the frame. Two thick pads of felt are sewed 
on the canvas, each 7 inches long and J inch thick, to 
protect the hump from pressure and to increase the 
leverage of the apparatus. Mangle felt is excellent for 
orthopedic purposes. There should be a small square of 
rubber covered with muslin at the region of the buttocks. 


342 


THE OPERATING ROOM 


To make the frame more effectual it may be bandaged 
with strong muslin bandages, with edges turned in, be¬ 
fore applying the laced canvas top. This frame is grad¬ 
ually bent, under the kyphosis, to curve upward from 
the bed to the hump, the ends resting on the bed. This 
obliterates the hump in time. Much orthopedic work 
with braces, frames, and suspension apparatus is really a 
daily Cl ‘operation’’ by the nurse. The child is taken off the 
frame daily, handled painlessly, bathed, rubbed with 
alcohol, and powdered. It is essential to have two canvas 
covers for each frame. To secure the patient to the 
frame an apron of canvas, covering the child’s chest from 
the armpits to the hips, is provided, with three pairs of 
straps of webbing and buckles, fastening in the back on 
the under side, immobilizing his body. The fixation must 
occur in the region of the disease— i. e., for lumbar disease 
a broad binder should be passed over the hips, and if 
there is psoas spasm, traction is usually employed. 

Buck’s Extension (Fig. 49).—This consists of the fol¬ 
lowing parts, all of which should be kept together in a 
set in a chest: 

(1) Two strips of moleskin plaster, each 2 or 3 inches 
wide and extending from the seat of the fracture to the 
internal malleolus. 

(2) An alcohol flame to melt the adhesive. 

(3) Two pieces of webbing for each leg, to be stitched 
to the plasters at their ankle end, 2 or 3 inches wide and 
6 inches long. 

(4) Five other strips of moleskin, each 1| inches wide, 
to encircle the leg, the knee, and the thigh, also to extend 
spirally from the malleoli around the leg and thigh to the 
seat of fracture. 

(5) Roller bandage of 3-inch muslin, with the edges 
turned in during application, then stitched in neat rows, 
to be kept in place. 

(6) A curved or straight ham, or posterior, splint prop¬ 
erly padded. 

(7) Three coaptation splints to surround the thigh. 


DUTIES OF NURSE IN ORTHOPEDIC SURGERY 343 

(8) Six webbing straps with buckles or strips of ban¬ 
dage to be used as straps. 

(9) Fresh sheets, pillow-slips, or towels as pads. 

(10) A straight abdominal binder for the pelvis. 

(11) A long axillary or outside splint of wood, 4 inches 
wide, from the axilla extending 6 inches below the sole 
of the foot. 

(12) To this is nailed a cross-piece 18 inches long, 
making a T. 




Fig. 49.—Apparatus for Buck’s extension, with rope and weights. 

(13) Two towels, soft and old, or 2\ yards of flannelette 
(one-fourth the width) for a perineal strap. 

(14) Safety-pins arranged with their points in a cake of 
Castile soap. 

(15) A pulley, screwed into a broom-handle cut the 
right height or attached to a special iron bar (part of the 
set) that clamps in two places to the bed frame. 

(16) A spreader, being a piece of wood 2 inches wide 
and a little longer than the width of the patient’s foot, 
with a hole bored in the center for the cord, on which hang 
the weights for extension. 












344 


THE OPERATING ROOM 


(17) A piece of clothes-line (cotton rope) 4 or 5 feet 
long. 

(18) Two shock blocks to elevate the foot of the bed. 

(19) Four sand-bags with white muslin slips, each 
20 inches long and 6 inches wide. 

(20) A square cradle, made of pine, fir, or cedar, to keep 
the weight off the limb. 

(21) A soft, warm old blanket for the limb, lying closely 
over it. 

(22) Cotton covered with gauze to stuff into corners 
(this prevents fluff from spreading through the bed). 

(23) A fracture-board or a plain level old door, with 
holes bored through it to air the mattress on the under 
side. 



Fig. 50.—Fracture-box. 


(24) Needle, thread, thimble. 

(25) Tape-measure. 

(26) Weights, graduated and recorded as to amount, 
when used. 

(27) Anesthesia set, vaselin, pus basin, towels, etc. 

(28) A railroad (old-fashioned, but still in vogue)—a 
track of wood on which the leg glides smoothly. 

Such a list as this, combining with the basic articles 
here enumerated any favorite materials of the operator, 
should be posted in the treatment room where this sort 
of work is done. 

Jury Mast.—A frame of tempered steel, leather straps, 
and canvas to straighten and lengthen a curved spine, 
including as points of support the brow and chin and a 







DUTIES OF NURSE IN ORTHOPEDIC SURGERY 345 

point in the plaster jacket well below the deformity. 
Each must be accurately fitted to the individual and 
altered to suit his development. The hump must be 
well padded. Even with the most careful intentions 
frightful pressure-sores are caused by inexpert handling. 



Fig. 51.—Sayre’s suspension apparatus for application of plaster 
jacket, or exercises. 

Fracture-box.—A support for the leg when the tibia or 
fibula is broken (Fig. 50). 

Sayre’s Suspension Apparatus.—A tripod, joined flex¬ 
ibly at the top and securely fastened when in operation 



346 


THE OPERATING ROOM 


by spikes into the floor. From the center at the top on a 
pulley runs a halter, adjustable to a collar, that thus sup¬ 
ports the patient by the neck and chin. It is fitted to 
him, and he is then slowly raised until his toes are just off 
the floor. Then over only a knitted undershirt, with the 
proper pads and “scratcher,” a plaster jacket is applied 
(Fig. 51). 

Modified Buck’s Extension for Hip Disease.—There is 
no splint as for fracture, merely the weights. The patient 



Fig. 52.—Fracture and orthopedic table in position for treating 
fracture of the lower extremity—adaptable to rontgenographic 
examination. 


is secured around the waist by a folded towel from which 
a bandage runs up to the head of the bed. With large 
children a perineal strap may be used. In any case the 
foot of the bed may be elevated. 

Orthopedic Tables.—It is most unusual to find a stand¬ 
ard orthopedic table outside the special hospital, but it is 
an excellent though very expensive article, consisting of a 
series of contrivances for procuring leverage, elevation, 
gaps to pass bandages, extension, z-ray, etc. (Figs. 52, 53). 


























DUTIES OF NURSE IN ORTHOPEDIC SURGERY 347 

Plaster Bandages.—In hospitals where orthopedic sur¬ 
gery does not constitute a special branch of work there 
are at least many occasions when plaster casts must 
be applied. To make the bandages are required: 

(1) A large flat tray. 

(2) The best of crinoline, of a standard fineness and 
thickness, this being the foundation of the whole system. 

(2) Excellent dental plaster of Paris. 



Fig. 53. —Fracture and orthopedic table, illustrating control of the 
leg in bone-plating for fractures. 

(4) A spatula to apply the plaster to the crinoline, 
though most nurses prefer to go ahead with the bare 
hands. 

(5) A tape-measure and stout scissors to measure, cut, 
and roll the crinoline in 5-yard lengths of the usual widths 
—3, 4, 5, and 6 inches—selvages cut off, also four or five 
threads raveled off. 

(6) Small round tin boxes, one for each bandage, lidded, 
in paper napkins or squares of blue tissue such as comes 
with cotton to roll up each bandage separately, then 










348 


THE OPERATING ROOM 


laying them on their side in a larger square tin box, with 
lid, to be kept perfectly dry. 

(7) A rubber apron and, if the skin is abraded or 
suffers from contact with irritating clays, thick rubber 
gloves. 

(8) A solid stool and table with foot-rest. 



Fig. 54.—Curved plaster-of-Paris knife. 


The bandage must have all the plaster it can hold, and 
this must be evenly distributed throughout its whole 
length. It is set on the left-hand side, unrolled, filled 
with plaster, much lying under it on the tray, smoothed, 
and rolled up to keep it ship-shape on the right as one 
goes along. It must be rolled only about 75 per cent. 



Fig. 55.—Saw for plaster-of-Paris cast. 


tight—that is, fairly loose—so that water may circulate 
between the layers of plaster later. 

It must always be handled very gently. It is of vital 
moment to keep up the stock of plaster bandages. If on 
any one day they run too low, they should be replenished 
that same day before the nurses go off duty. 










DUTIES OF NURSE IN ORTHOPEDIC SURGERY 349 

For putting on a cast the following articles are required: 

(1) Gown,'rubber apron, and unsterile rubber gloves 
for the surgeon (also rubbers with high tops to cover his 
shoes, if he chooses). 

(2) Newspapers, rubber sheets, etc., to cover the floor. 

(3) Ammonia, alcohol, or vinegar to soften the old 
cast or cleanse the hands. 


Fig. 56.—Plaster-of-Paris shears. 



(4) Special knife, saw, and shears for cutting casts 
(Figs. 54-56). 

(5) Stockinet, shirt, drawers, or stockings of cotton or 
Balbriggan to protect the body (the pupils should save all 
their cast-off white hose for this purpose, especially for 
arm cases); bandages of stockinet are good for any por¬ 
tions of the body not ordinarily clothed with knitted 
goods. 


350 


THE OPERATING ROOM 


(6) Mangle felt in strips or squares, to pad or give 
elasticity with compression. 

(7) Sheet-wadding, glazed, preferable to cotton, in 
many rolled strips, 4 inches by 1 yard. 

(8) Cotton, alcohol, and powder to rub and pad all 
humps or edges, even after everting the stockinet cuffs. 

(9) Oiled silk, to form at the edges near the genitals 
a surface impervious to urine or stool. 

(10) Hip rest of metal or wood (also convenient for the 
spica in hernia) if no orthopedic table is to be had. 

(11) A large enamel basin, 8 inches deep, in which to 
set the bandages on end, with plenty of space for the 
water to submerge them plus the nurse’s hands, without 
overflow. 

(12) Water at the temperature of 100° F., kept so by 
adding hotter from time to time from a pitcher nearby; 
a bath thermometer. 

(13) A solid table protected with rubber sheets, large 
and small, and an old cotton blanket. 

(14) Old soft blankets on the patient; warm-water 
bottles, each with two covers not warmer than 110° F.; 
a burn through a cast, not being easily discovered, is apt 
to be very deep and lasting. 

(15) Cotton rollers—tear sheet wadding lengthwise in 
desired widths and sew two lengths together and roll. 

(16) Plaster bandages, 3, 5, 7 inches. 

(17) Gauze bandages,1, 2, 3 inches. 

. (18) Muslin bandages, 1, 2, 3 inches. 

(19) Gauze. 

(20) Iodin, 4 per cent. 

(21) Heusner’s glue with brush. 

(22) Extra plaster and spoon. 

(23) Salt. 

(24) Doctor’s towels, gown, gloves, powder. 

(25) Two pails and a colander. 

(26) Equipment for anesthesia, p. r. n. 

Special Instructions to the Nurse. —(1) Set the ban¬ 
dages on end, only one at a time, and hold them so with 


DUTIES OF NURSE IN ORTHOPEDIC SURGERY 351 


both hands until they are wet through. Bubbles begin 
to rise continuously in their center, and when these bubbles 
cease they are wet enough. 

(2) Squeeze the bandage until one-half the water oozes 
out, then hand it to the surgeon so that he may take 
the bulk of the roll in his right hand and the free end in 
his left. The distance from the nurse’s basin to the 
surgeon’s hand should be the shortest possible. 

(3) Just as soon as the nurse relinquishes one bandage, 
she removes the wrapper and steeps a second, that time 
corresponding to the length of time required by an ex¬ 
pert orthopedic surgeon to apply one. 

(4) When all are on, she should, with both hands, 
scoop up the sediment left after pouring off the bulk of 
the water and pass it to the surgeon or keep it soft and 
equally mixed while he makes with it an extra coat quite 
smooth over all. 

(5) At times it is necessary to bolster the cast by first 
applying a plaster splint which is best made on the oper¬ 
ating-table. Therefore a space must be cleared by flex¬ 
ing the patient’s other knee, or on the work-table used by 
the nurse, a glass or rubber surface being preferable. 
The measure is taken on the limb, then a wetted bandage 
is laid flatly on the table and folded on itself longitu¬ 
dinally. If this were a 5-inch bandage it would make 
five thicknesses 1 yard long and 5 inches wide, which 
would probably be thick enough. These splints are al¬ 
ways made the single width of the bandage provided. 
Their length depends on the bone being set. 

(G) When a cast has been put on, the old cast is broken 
up into small fragments to fit the trash-cans easily, and 
to avoid scaring some one who comes across a ghostly 
limb in the dark basements. 

Most important of all, the plaster must not he poured into 
the sink or hopper, since it sets and stops up the plumbing. 
The basins should be scooped out into papers, thickly 
wrapped about, and put into the trash-cans. 

Adhesive Plaster Strapping for Flat-foot.— Adhesive 


352 


THE OPERATING ROOM 


plaster, 15 inches long and 3 inches wide, beginning at 
the outer side of the ankle just below the external malle¬ 
olus. Adduction of the foot (drawing it up inwardly to 
form an artificial arch). Passing the plaster tightly under 
the sole, up the inner side of the arch and leg. Two small 
strips of plaster, 1 inch wide, crossing it at the top, to keep 
it in place, but not completely encircling the leg lest they 
cut off the circulation. Measure with a tape before 
cutting. Then cut a series of six strips of adhesive, 
15 inches long and f inch wide, and cover this same 
area again, laying the back edge of each over the front 
edge of the one preceding, and catching them alternately 
in a braided or basket pattern, coming down from the 
top, with small strips running horizontally, working down 
to the malleoli, but leaving an open path down the in¬ 
step, 1J inches wide, which may be bordered with two 
strips of the proper length to cover the raw edges. Over 
all apply a firm bandage. This should be removed once 
a week with ether or benzine, the foot examined and 
cleansed, then dressed again. 

The Lorenz operation for congenital dislocation of the 
hip, consisting of bloodless reduction, retention, weight 
bearing. 

For bloodless reduction no instruments are required 
but the surgeon’s hands; a thick folded sheet beneath the 
patient’s buttocks; a wedge of wood (for all but tiny 
children) about 5 inches long, 3 inches wide, and suitably 
padded to form a fulcrum under the head of the femur; 
a second sheet folded diagonally to make traction from 
the perineum, with the ends tied about a corner of the 
table. 

If the reduction requires two sittings, a plaster spica is 
required for the first, and certainly after the last. The 
following special articles are to be provided: 

(1) A cl °se-fitting long stockinet shirt, one-half of 
which is cut and sewed to cover the limb as a drawer leg 
would do. 

(2) This drawer is “threaded” with a long bandage, 


DUTIES OF NURSE IN ORTHOPEDIC SURGERY 353 


called the scratcher, which runs down as a loop inside the 
drawer and up outside the cast, to give the patient or 
nurse a means of rubbing the skin underneath when it 
itches. 

(3) The hip or pelvic rest to elevate the body for all 
spica work. 

(4) Sheet-wadding, with glazed surface preferably, or 
cotton in long rolled strips, 4 inches wide, to cover the 
pelvis and thigh thickly. 

(5) A firm bandage of muslin for elasticity and com¬ 
pression (may be preceded by a fine smooth gauze ban¬ 
dage). 

(6) The plaster spica, very thick and firm, consisting 
of a dozen or more ordinary plaster bandages, embracing 
the iliac crests, the buttocks, and the leg to, but not over, 
the knee-joint. 

(7) Plaster scissors to cut away the edges; then they 
are everted. 

(8) Stout thread with needle to sew the stockinet 
(when it is smoothly turned up over the edges) to it¬ 
self. 

(9) The stimulation tray with the anesthesia set, be¬ 
cause deaths occur from the violence of the rupture of 
these congenital adhesions under the anesthetic. 

(10) A cork sole of 1| to 3 inches in thickness should 
be early ordered for the affected foot when walking begins 
in the third week. 

Transplantation. —For ununited fracture, Pott’s disease, 
etc., a very small piece is excised from the fibula (usually) 
and dovetailed into a crevice hewn out of the affected area. 
The hole in the leg is replaced by healthy, granulating 
bone tissue, not callus. 

Callus occurs in fractures. Small pins or dowels of 
fibula bone are inserted or mortised into holes drilled in 
the graft to maintain it in situ , just as a clever cabinet¬ 
maker secures the parts of a chair with pegs. The tools 
are automatic, electric driven, reducing the shock of the 
operation by their speed. When a man is shot with a 
23 


354 


THE OPERATING ROOM 


fast bullet he does not know he is shot till he sees the 
blood. These tools must be divided into two classes, 
Boilable, 

Non-boilable, 

and woe betide the nurse who errs. The operation is very- 
spectacular, and stirs up much interest on account of the 
universal appeal of tuberculous patients. The saw must 
be kept wet. 

Poor and improperly prepared materials hamper the 
orthopedic surgeon very greatly. He is a surgeon plus. 
He has to have a true eye, and the skill of a sculptor, 
as well as the usual qualities of the surgeon. Imper¬ 
fect results are charged against him very loudly and 
long by a disgruntled patient, because of the value, 
to us all, of a perfectly working arm or leg, both in a 
cosmetic and a commercial sense. The imperfection of 
the result must not be traceable to any flaw in operating- 
room methods. No matter how much natural aptitude or 
knack the surgeon has, he requires good support in 
Good crinoline, 

Good plaster, 

Well-made bandages, 

Expert soaking and handling of same. 

Making plaster bandages is a regular part of operating- 
room training and should not be relegated to orderlies. 
Each pupil may be a future supervisor who should teach 
that, in no matter how metropolitan or remote a place. 
The Cook Plaster Bandage Machine is used successfully 
in Hartford Hospital, Hartford, Conn., as invented by 
Dr. Ansel G. Cook of that city. (See Modern Hospital, 
vol. xxi, No. 4, October, 1923.) 

A New Plaster Knife.—A recent issue of the Journal of 
the American Medical Association, vol. 82, No. 1, Jan¬ 
uary 5, 1924, contains an article of interest relating to a 
new plaster knife (Fig. 57), which reduces the fears of the 
patient as compared with the ancient pruning-hook. 

This knife is designed to facilitate the cutting down of 
plaster casts and comprises a handle, shaft, removable 


DUTIES OF NURSE IN ORTHOPEDIC SURGERY 355 

standardized blades, and a hand rest for pressure on the 
blades, an eight-pointed revolving wheel on the under 
surface of the shaft, and a pick at the end of the handle. 
The accompanying illustration shows the parts of the 
knife individually and assembled for operation. 

Two knife blades operate parallel to each other at one 
end of the knife, with their beveled edges away from each 



Fig. 57.—A new plaster knife designed by Herman B. Philips, 
M. D., New York: Above, assembled; below, individual parts. 


other. They serve to cut a strip of plaster, thus obviating 
any possibility of jamming of the knife blades, which is a 
common occurrence with the usual type of plaster knife. 
The blades are standardized and easily replaced by un¬ 
screwing a circular knob, which holds them in position. 
The change of blades can be accomplished in a few seconds. 
The knob serves an additional purpose of permitting 






356 


THE OPERATING ROOM 


pressure directly over the blades, so that more effective 
cutting can be assured. Just back of the knife blades is 
a rod pointing downward, supporting a revolving, sharp- 
pointed wheel. The wheel also serves a double purpose: 
first, that of cutting up the plaster strip made by the two 
knife blades, and second, that of affording a pivot on 
which the shaft of the knife operates, so that depression 
of the handle elevates the blades and, vice versa, the 
elevation of the handle depresses the blades and makes 
them cut deeper. At the end of the handle is a pick, 
which is used to pry open the plaster. 

The knife has proved to be of considerable help, saving 
time and strength in cutting down plaster casts, in making 
fenestrations, etc. 

Advantages. —1. This plaster knife can be made to cut 
superficially or deeply. 

2. Margin of safety. 

3. Blades standardized, easy to put in. 

4. Knife permits rapid and easy work. 


CHAPTER XXI 


IMPROVISED OPERATING ROOM IN A PRIVATE 
HOUSE 

When Needed. —With modern facilities for travel and 
the ever-increasing construction of hospitals, conditions 
requiring improvisation will likely exist only in the case 
of virulent contagion with surgical sequelae, in the remote 
wilds, or in homes of means, where some personal feeling 
regarding hospitals or preference to keep small children 
at home masters the situation. Where unjust staff rules 
in a hospital shackle a majority of the community, much 
minor surgery can be and is quickly and effectually done 
in the home, and creates an interesting, profitable field 
for special nurses. Every nurse should cultivate the 
power of improvisation in this and all other departments, 
so as to save even the smallest expense, which even the 
wealthiest appreciate, a quality often lacking in institu¬ 
tional life where the persons who really pay the bills are 
never seen. 

Progress in Serving Communities. —Just as the army 
equipped mobile operating-units, so, when necessary, 
single, isolated, or community hospitals may equip and 
send forth on a truck, the tables, goods, basins, flasks, 
and staff, who stretch a clean canopy in the room, and 
operate under favorable conditions. Naturally, the only 
doctor who may do this is one who has full staff privileges, 
hence the proper conception of the relation of the hospital 
to the community must be held by the directors. 

Preparation of Room. — (a) For immediate operation, 
do not stir up ancient dust, but hang sheets. For twenty- 
four-hours’ preparation take down everything, and dust, 
washing with bichlorid of mercury after the dust settles. 
Carpets must be removed (as a source of dust) or covered 
with oilcloth (impervious to any that could rise). 

357 


358 


THE OPERATING ROOM 


(6) Windows must be obscured by smearing with Bon 
ami, and the daylight rendered equally diffuse. 

(c) Furniture of wood which must be used must be 
protected with oilcloth and thick pads of old newspapers, 
confined in thin old sheets. 

(i d ) Lighting by kerosene lamp or gas is prohibited 
when using ether, which is inflammable and volatilizes in 
a long, continuous, invisible train which rises and by and 
by connects with the flame—hence, operate by daylight, 
electricity in the house, or batteries brought by the 
surgeon. The powerful searchlight on an automobile 
may be used to advantage. 

The Tables. —The surgeon may bring an office table or 
regulation operating-table: (a) Usually an extension table 
is employed, fully extended, and the middle leaves re¬ 
moved, but a small square board inserted, same width 
as the patient. All is well padded, and protected from 
moisture and stains. The width of the two ends makes 
enough space for the operator’s instruments and the 
anesthetist’s outfit. The surgeon and his assistant stand 
in the “waist.” (6) For very small cases, such as tonsils, 
or circumcisions, a stout kitchen table is best, being 
hard to spoil, but very solid, (c) For improvised Tren¬ 
delenburg, which is not likely to be attempted in house 
operations, one can slip a chair, face down and well 
padded, on the foot of the table, or an assistant standing 
between the patient’s thighs raises her legs over his 
shoulders, standing with his back to her, or one may ele¬ 
vate the foot of the table with blocks, boxes, or solid 
chairs, propping the other end to keep it from sliding. 
(d) For a sponge and instrument table an ironing-board 
passed through the first and third panels of a clothes- 
horse, and all covered with sterile sheets, makes a safe 
place, easily set up and put away, (e) For a bed opera¬ 
tion, always put an ironing-board or a leaf of an extension 
table on the bed frame under the springs, at the patient’s 
buttocks, for firmness. 

The Anesthetist. —He requires a large soap dish or 




IMPROVISED OPERATING ROOM IN A PRIVATE HOUSE 359 


Fig. 58.—Closed method of anesthesia. 


- 


Fig. 59.—Open method of anesthesia. 








360 


THE OPERATING ROOM 


soup plate, as a kidney basin, and a cone for ether, for the 
closed method (Fig. 58) made out of a towel and a folded 



newspaper, or, for the open, or drop method (Fig. 59) a 
piece of flannelette over a tea or coffee strainer. Most 


Fig. 60.—Improvised stretcher. 




IMPROVISED OPERATING ROOM IN A PRIVATE HOUSE 361 

anesthetists carry their outfits. For stimulation the 
nurse has her own hypodermic syringe as usual. 

The Stretcher. —A stretcher is made by laying two 
square chairs face down on the floor, their feet meeting. 
The legs are very solidly spliced and a piece of board 
laid and fastened in the center, then the whole covered 



Fig. 61.—Improvised Kelly pad. 

with blankets and draw-sheet. The upper ends of the 
chair or the top cross-piece make a secure handle. This 
stretcher stands at a good height by the bed for lifting 
the patient on or off with the aid of a folded sheet (Fig. 60). 

Improvised Kelly Pad. —If vaginal work is to be done 
a Kelly pad (Fig. 61) is improvised as follows: Required, 




362 


THE OPERATING ROOM 


a blanket, old and soft; adhesive strips, 6 by 2 inches; a 
rubber sheet or a piece of oilcloth, 2 yards by 1 yard; 
two hemostats; eight pieces of gauze bandage each 12 
inches long. Roll the blanket tightly and tie it in one 
long cylindric roll. Lay it on the farther long edge of 
the rubber and roll toward the nurse, about two turns. 
Divide into three equal parts, the middle part at least 
being 2 feet wide. Grasping the roll firmly, turn at the 
first third at a right angle. Do the same with the last 
third. This leaves a triangle outside each side of the 
“Kelly pad.” Reduce these triangles by folding to one- 
half their size, bring over the roll, interiorly, and fasten 
with adhesive, artery clamps, or, at the worst, safety-pins, 
in the oilcloth only, not through an expensive rubber. 
Let the apron hang over into the waste pail. The whole 
resembles a soldier’s blanket on the march. 

Nurse’s Supplies.—(1) Cold sterile water, boiled in 
clean kettles the night before for a morning operation. 
Have enough kettles. 

(2) Hot sterile water, boiled similarly a short time 
before the surgeon’s arrival. 

(3) Clean towels, old pieces of muslin of the size of a 
towel, put up in packages the day before, and sterilized 
as follows: Tie a cloth from handle to handle of a clothes- 
boiler to make a flat hammock above 2 gallons of water, 
and on that lay the packages. Lay the lid in position, 
and to its handle tie a heavy smoothing-iron to hold it 
down (“steam under pressure” or confined). Turn on 
the gas and boil for one hour. Remove the iron gently, 
then the lid very gently, so as not to permit the drops to 
fall on the packages. Lay them in a clean dry place to 
become perfectly dry, or dry them in the oven. 

(4) Laparotomy sheet, table covers, etc., may be made 
out of sheets, pillowslips, etc. Do not destroy a good 
sheet for a laparotomy. Rather pin in position four 
pillowslips, fold, and sterilize. 

(5) Saline made within the same day it is used requires 
only one sterilization. Two 1-quart bottles are sufficient. 


IMPROVISED OPERATING ROOM IN A PRIVATE HOUSE 363 


The saline is made and boiled, if possible, the day before, 
filtered, and poured into two boiled bottles, which are 
then plugged with gauze and cotton and sterilized with 
the dressings. By being made triple strength and diluted 
twice with cold water, they can be cooled for use if ster¬ 
ilized again the day of the operation (set in a container 
of water and brought to a boil, then kept at boiling-point 
one hour). 

(6) Vaselin, as a sterile lubricant, is set in its con¬ 
tainer (lid separate) in cold water, not quite to the edge, 
then brought to a boil and kept boiling for one hour. 
After cooling in the container (burned fingers being res 
non gratce at this time) it is aseptically lidded and set 
aside. A small amount is taken out on a sterile grooved 
director when needed. 

(7) Basins for the hands during the case will be found, 
from the gray enamel to the white stone china, in an 
old-fashioned bedroom. If enamel or china, they are 
disinfected by standing in bichlorid of mercury solution 
1 : 1000 (preceded by vigorous scrubbing and rinsing). 

(8) For an irrigator (seldom used) a boiled douche- 
bag or can, covered with a towel and hung on a weighted 
hat-tree with smoothing-iron or brick tied to the feet so 
that it will not topple, may be used. 

(9) Instrument boiler, dish pan or fish boiler—must be 
long and not too narrow. 

Surgeon’s Garments. —Usually a man undertaking this 
work has, and will bring his garments, dressings, sheets, 
and towels. But if he were alone in the wilderness, hunt¬ 
ing, with only his guides, he should be able to do fairly 
efficient work, as follows: 

(a) Cap: A handkerchief, or piece of any washable 
material. A piece of gauze 1 yard square brought (doubled 
diagonally) from the back of the neck, barely escaping the 
tips of the ears and tied on the brow, with the central 
point tied in with it, makes a cool, serviceable cap. 

(b) Mask: Improvised masks are made as follows: 
A piece of gauze \ yard square is, before the person scrubs, 


364 


THE OPERATING ROOM 


laid up on his chin. The lower two points are twirled and 
tied up on top of his head. The upper two corners are 
twirled and tied over and behind the ears. Gauze or thin 
old handkerchief. 

(c) Gowuis: A loose pyjama coat with a skirt made of a 
draw-sheet and put on backward makes a practical gown. 
Nature is often very merciful bo those wounded in the 
wilds. 

Preparation of Patient.—This must be done simulta¬ 
neously with the other work in the regulation hospital 
manner. 

Demonstration.—In the last week of the suture nurse’s 
service she should prepare, before the staff, a complete 
operating-room equipment in a private room: 

(1) Using no technical hospital equipment. 

(2) Minimizing expense, and giving table of costs. 

(3) Taking the steps in chronologic order: 

(a) Making saline and dressings. 

( b ) Preparing the room. 

(c) Sterilizing goods. 

0 d ) Preparing patient, 

although not actually consuming the required time. She 
should be able to go into any home and give promptly a 
correct estimate of the articles needed and the length of 
time required for the various types of cases. 

In the New York Post-Graduate Hospital the very prac¬ 
tical work done, each year, at graduation, in the interesting 
public demonstration including this feature, has proved of 
enormous value to all its students in their after careers, 
whether as private nurses or teachers of others, visiting 
nurses or those more fortunate, glorious women who 
served their country in the late war, on the firing-line, 
with their surgeons, everywhere, under dropping shells, 
on canal barges, in hospital tents, or beneath the open sky. 


CHAPTER XXII 


THE IDEAL SURGEON 

Nurses should pause, in the early days of their operat¬ 
ing-room service, to reflect that, of the enormous mass of 
detail that they are privileged to view here, all was dis¬ 
covered by thousands of surgeons, at different periods, 
from five centuries before Christ, to the present day, of 
many nationalities, including Greece, Rome, Germany, 
Belgium, modern Italy, and Britain. The first American 
surgeon became known about 1750. It is tonic to look 
far back, and realize that the Old World initiated and per¬ 
fected what we now enjoy by copying. It is none the less 
necessary to look far into the future and visualize the 
surgery of a later era, wondering what can yet be dis¬ 
covered. Here are a few sketches of men who loved 
their fellow beings, and in trying to help certain ills, 
benefited all humanity. It is hoped that some such one 
will arise and bring a cure for cancer and the remaining 
diseases that puzzle and baffle modern science. In the 
roll of fame, many names of surgeons stand out con¬ 
spicuously, because the debt owed them in lives, health, 
and community prosperity is incalculable. 

Hippocrates. —Much is due the early Greeks, a nation 
that pursued intellectual interests, for the foundation of 
surgery. Hippocrates, who was born about 470 B. C., in 
a family of medical traditions, not only swore his famous 
oath, thus becoming our recognized, complete guide in 
ethics, but performed and wrote of trephining, herniotomy, 
thoracotomy and even suprapubic lithotomy. 

“I swear by Apollo, the physician, and iEsculapius, and 
Health, and All-heal, and all the gods and goddesses, that 
according to my ability and judgment, I will keep this 
oath and stipulation: to reckon him who taught me this 
365 


366 


THE OPERATING ROOM 


art equally dear to me as my parents, to share my sub¬ 
stance with him and relieve his necessities if required; to 
regard his offspring as on the same footing with my own 
brothers, and to teach them this art if they wish to 
learn it, without fee or stipulation, and that by precept, 
lecture, and every other mode of instruction I will impart 
a knowledge of this art to my own sons and those of my 
teachers, and to disciples bound by a stipulation and oath, 
according to the law of medicine, but to none others. 

“I will follow that method of tretament which, according 
to my ability and judgment, I consider for the benefit 
of my patients, and abstain from whatever is deleterious 
and mischievous. I will give no deadly medicine to any¬ 
one if asked, nor suggest any such counsel; furthermore, I 
will not give to a woman an instrument to produce 
abortion. 

“With purity and with holiness I will pass my life and 
practice my art. I will not cut a person who is suffering 
with stone, but will leave this to be done by practitioners 
of this work. Into whatever house I enter, I will go into 
them for the benefit of the sick and will abstain from 
every voluntary act of mischief and corruption; and fur¬ 
ther from the seduction of females or males, bond or free. 

“Whatever, in connection with my professional practice, 
or not in connection with it, I may see or hear in the lives 
of men which ought not to be spoken abroad, I will not 
divulge, as reckoning that all such should be kept secret. 

“While I continue to keep this oath unviolated, may it 
be granted to me to enjoy life and the practice of the art, 
respected by all men at all times, but should I trespass 
and violate this oath, may the reverse be my lot.” 

Galen.—Equally familiar is the name of Galen used in 
the expression, “sitting at the feet of Galen,” to signify 
studying medicine. Galen was born about 131 A. D., in 
Greece, six hundred years later than Hippocrates, and 
twelve hundred years before de Chauliac, remaining the 
leader of medical thought for sixteen centuries. He it 
was who discovered and demonstrated in surgical practice 


THE IDEAL SURGEON 


367 


the nature and duties of the arterial system, more espe¬ 
cially anastomosis and ligation. 

Guy de Chauliac.—An interesting article appeared 
among the book reviews in a recent issue of the Journal 
of the American Medical Association, 1 which presents in 
ideal, concise way the qualities necessary in a surgeon, 
who is in a very responsible position, when educational 
preceptor for interns and nurses who must from him 
alone absorb the principles underlying their own future 
conduct toward their clientele. 

“Guy de Chauliac, generally known as the ‘Father of 
Surgery/ was born in France in the last years of the 
thirteenth century. Like most of the surgeons of his time, 
he practised under the patronage of a feudal lord. He 
studied in Montpellier, Bologna, and Paris, and was 
physician to several of the popes, who conferred special 
dignities on him. When he compiled his great surgical 
text-book, copies were promptly made in various languages. 
The English edition was first published in 1541. The 
great work consists of seven parts, including anatomy, 
apostems, wounds, ulcers, fractures and dislocations, 
special diseases, and antidotes. 

“Mr. Brennan’s text opens with the famous description 
of the qualities of a surgeon: 

“The conditions necessary for the surgeon are four: first, he should 
be learned; second, he should be expert; third, he must be ingenious, 
and fourth, he should be able to adapt himself. It is required for the 
first that the surgeon should know not only the principles of surgery 
but also those of medicine in theory and practice; for the second, that 
he should have seen others operate; for the third, that he should be 
ingenious, of good judgment and memory to recognize conditions; and 
for the fourth, that he be adaptable and able to accommodate himself 
to circumstances. Let the surgeon be bold in all sure things, and fear¬ 
ful in dangerous things; let him avoid all faulty treatments and prac¬ 
tices. He ought to be gracious to the sick, considerate to his asso¬ 
ciates, cautious in his prognostications. Let him be modest, dig¬ 
nified, gentle, pitiful, and merciful; not covetous nor an extortionist 
of money; but rather let his reward be according to his work, to the 
means of the patient, to the quality of the issue, and to his own 
dignity.” 

1 Guy de Chauliac (A. D. 1363), On Wounds and Fractures. Trans¬ 
lated by W. A. Brennan, A. B. 


368 


THE OPERATING ROOM 


“In selecting from the complete text, Mr. Brennan has 
chosen wisely, giving a view of not only the surgical work 
such as ligature and suturing, but also bandaging and the 
application of drugs. The translation is simple and very 
well done.” 

It would be attempting to paint the lily to comment 
on this description further than to emphasize the need 
for nurses to be reserved and careful in their judgments of 
the mental and moral caliber of those under whose direc¬ 
tion they work, and to gage them silently by this fine, 
sure standard, which covers every phase of their work 
in a manner parallel to that implied in the Pledge of 
Florence Nightingale and the Oath of Hippocrates. 

Vesalius.—The modern method of developing success¬ 
ful surgeons is based on the dissecting of the cadaver, 
with lectures, then assisting in the operating room while 
intern, where latent talent may appear. Even the nurse, 
who is only humble handmaiden to the operator, works 
more intelligently, by quick anticipation of needs, after 
having seen dissection in specimens and necropsies. In 
1514, in Brussels, was born Vesalius, inheriting strong 
leanings toward surgery from a long line of ancestors, 
and educated at the wonderful old University of Louvain, 
the restoration of which, since its destruction by the Ger¬ 
mans in the Great War, has occupied the mind and heart 
of so many Americans. He had to cope with tradition 
and fierce prejudice in his efforts to teach anatomy by 
dissection, and while his students adored him, the con¬ 
servative world was arrayed against him, much as now 
on vivisection, when the only way to make and ensure 
certain discoveries is promptly howled down by per¬ 
manent groups of destructive critics. But he established 
the method, and it will always stand. 

Pare.—To this great Frenchman, 1510-1590, we owe 
our knowledge of proper handling of gunshot wounds 
(letting them alone) and the end ligature in amputation 
stumps. It must have been a joy to the patients in the 
then nine centuries old Hotel Dieu, in Paris, when this 


THE IDEAL SURGEON 


369 


young house doctor, only twenty-three, for the first time 
in the world treated his patients painlessly, applied soft, 
comfortable dressings, cleansed the wounds, and stayed 
them with deft roller bandages. That was four centuries 
ago. What must his ghost have thought when he saw 
troops of .American nurses invade Paris! 

Hunter.—Crossing from the continent to the “right little, 
tight little island,” we touch upon Hunter, born in Scotland 
in 1728. Educated in London, he became an expert 
student of anatomy, and on his observations is based all 
we are taught in training-schools about inflammation, as 
well as placental circulation and the function of the great 
middleman of our system, the lymphatics, with which we 
nurses have yet only a frigid bowing acquaintance. The 
chief inspiration to be gained from his life is that of end¬ 
less industry and boundless catholicity of tastes, embrac¬ 
ing with equal fervor geology and trout fishing. 

Moving ever westward, it is interesting to note the 
almost martyrdom of the early American gynecologist, 
McDowell, born in Virginia, in 1771, of whose life it is 
one of the fond traditions of the Woman’s Hospital that 
he was mobbed for days, heckled, jeered, and stoned when 
he performed the first ovariotomy, and that the jeers 
after a week turned to praise, and the stones to flowers. 

F. Marion Sims, later, born in 1813, true founder of 
gynecologic surgery, seeing how many women were con¬ 
demned to lifelong torment by dripping vesicovaginal 
fistulso, caused by the death of patches of tissue sub¬ 
jected to long pressure in difficult labor early in their 
married life, successfully experimented with silver wire 
sutures and relieved so many, rich and poor, that in 
gratitude the famous Woman’s Hospital in the State of 
New York was opened to extend his opportunities to do 
good. 

Lord Lister.—This kindly man, with his trenchant wit, 
but unassuming manner, lived till our own time, and 
links the present with the past for us by depicting the 
“laudable pus” calmly taken as a matter of fact, in every 

24 


370 


THE OPERATING ROOM 


wound, laudable if it did not kill, and the attending high 
death-rate in hospitals from sepsis. The deep hostility 
of our older generation, our own grandfathers, to hos¬ 
pitals, is in the main, based on stories handed down to 
them from the first quarter of this nineteenth century. 
Nurses cannot imagine wards now without disinfectants, 
isolation of cases, and careful diagnosis on admission. The 
comfort and safety of modern hospitals is entirely due to 
Lister’s exposition and demonstration of the theory of 
antiseptics, from which the step to “asepsis” is painless 
and easy. The same air that Lister breathed stimulated 
Pasteur to his twin theory of the life of bacteria. The 
honors paid these men are now equal. Soldiers of every 
land felt more secure in following the flag since these men 
have lived and nations have delighted to praise them. 
When nurses see that so much can be accomplished for 
mankind within the span of one life our own behavior and 
line of thought unconsciously are lifted to a more dig¬ 
nified and lofty plane, being, in a humble way, partners 
in that divine emotion that supported famous men through 
long, hard days and nights, amid privations and rebuffs, 
to alleviate human ills. 

Author's Note .—The information of this chapter was 
compiled from well-known works on surgery, too numer¬ 
ous to mention. 


INDEX 


Abdominal paracentesis, 325 
Abscess of brain, incision of, 
instruments for, 273 
pharyngeal, incision of, instru¬ 
ments for, 280 
Accessories, 150 

Adenoidectomy, instruments for, 
278 

Adhesive plaster, applying, 75 
sterile, 195 

strapping for flat-foot, 351 
Air-shaft, 135 

Albee electro-operative bone set, 
88 

Alcohol, 337 

Aluminum acetate solution, 180 
Ambulance bags, 78 
Amputation of breast, instru¬ 
ments for, 282 
of leg, instruments for, 303 
Amyl nitrite, 64 
Anatomy, teaching, 100 
Anesthesia, classes of, 60 
closed method, 359 
consideration in, 52 
history of, 60 
local, 58 
methods of, 61 
open method, 359 
preparation for, 60 
rectal, 58 

rights of patient, 50 
spinal, 57, 320 


Anesthesia, stages of, 61 
Anesthetic nurse, 43 
instruction, 43 
needs of, 49 
room, setting up, 47 
Anesthetics, special, 57 
Anesthetist in operation in pri¬ 
vate house, 358 
nurse, 54 

Aneurysm needles, 292 
Apothecaries’ measure, 184 
Apparatus used in orthopedic 
surgery, 341 

Appendectomy, instruments for, 
285 

Applicators, cotton, for ear, 219 
toothpick, for eye, 219 
Aprons, rubber, 191 
Architect, 134 
Argyrol, 142 
Aristol pledgets, 218 
Artificial light, 115 
respiration, 321 
Asepsis, 158 
break in, 170 
definition of, 158 
history of, 167 
of drugs, preservation, 210 
preparation of nurse to com¬ 
prehend, 160 

Aspiration, instruments for, 283 
Autoclave, 140 
Avoirdupois, 184 




372 


INDEX 


Bacteria, floating, 167 
virulence of, 159 
Bacteriology, lessons in, 160 
Bags, ambulance, 78 
Bandages, gauze, 217 
muslin, 220 
plaster, 347 
Barriers of safety, 161 
Basins, sterilization of, 145 
Bed, Gatch, 68 

Bichlorid of mercury solutions, 
182 

Binder, breast-, 230 
Binders, applying, 29 
scultetus, 29, 228 
T-, 221 

Bismuth gauze drains, 186 
Blackboard, 122 
Bladder drainage, 68 
Blanket warmer, 141 
Blankets, 232 
Blood transfusion, 312 
Blood-letting, 316 
Blood-serum, injection of, 311 
Blunt needles, 80 
Bobbinette, linen, 220 
Bone plates, Lane’s, 87 
plating, 32 
transplantation, 353 
wax, 179 

work in osteomyelitis, instru¬ 
ments for, 304 
Boric acid solution, 180 
Bottle for Potain’s aspirator, 284 
Bougies, 193 
sterilization of, 146 
Bradford frame, 341 
Brain abscess, incision of, instru¬ 
ments for, 273 
Brandy, 337 

Breast amputation, instruments 
for, 282 


Breast funnel, 339 
Breast-binder, 230 
Buck’s extension, 342 

modified, for hip disease, 
346 

Building stretchers, 28 
Buried suture, 83 
Burr, electric, 198 
Buying for operating room, 335 
wisdom in, 103 


Cabinet, fumigating, 193 
Cabinets, 125 
instrument, 125 
care of, 196 
Calcium chlorid, 196 
Cannula, tampon, 216 
whistle, 216 
Cannule a chemise, 216 
Cap, ether, 51 
Capillarity, 84 
Caps, 231 

Carrel-Dakin solution, 176 
Carrying on the operation, 74 
Catgut, 179 
making, 85 

Catheters, rubber, 191 
silk, 193 

sterilization of, 145 
Cautery, 123 
Celluloid linen suture, 84 
Centigrade thermometers, 205 
Centimeter, cubic, 203 
Cervix needles, Sims’, 80 
Cesarean section, instruments 
for, 293 

Changing cases, 35 
Chemical sterilization, 127 
Chiropodists’ plaster, 220 
Cholecystectomy, instruments 
for, 288 



INDEX 


373 


Cholecystotomy, instruments 
for, 288 

Choledochotomy, instruments 
for, 288 

Cigarette drains, 287 
Circulating nurse, 23 
changing cases, 35 
control of special conditions, 
27 

dress of, 29 

during operations, regular 
duty, 30 
duties, 23 
learning, 26 

Circumcision, instruments for, 
301 

Clamp, tongue, 50 
Cleaning instruments, 197 
Cleanliness, perfect, 119 
Clock, 122, 142 
Cloth retractors, 220 
Club-foot, 341 
Cocain, 59 

solutions, methods of com¬ 
puting, 210 
Codes, printed, 143 
Coffee enema, 323 
Cold cream, hospital, 199 
College of Surgeons, 92 
Colors for solutions, 184 
Combination tables, 47 
Community, operating room as 
related to, 20 

Conducting an operating room, 
72 

Cones, ether, 222 
Congenital dislocation of hip, 
339 

Lorenz operation for, 
352 

Continuous suture, 83 
Corners, 117 


Cotton applicators for ear, 219 
balls, 218 
Counting linen, 28 
sponges, 41 
Covers, 227 
dressing, 232 
for packing tubes, 231 
gown, 231 

Crossen’s method of using gauze 
strip sponge, 213, 214 
Cubic centimeter, 203 
measure, 203 

Curetage, instruments for, 296 
Curvature of spine, 340, 341 
Cystoscopy, 317 
Cysts, 238 

Dakin’s solution, 176 
Deceits, 22 

Decompression operation, instru¬ 
ments for, 267 
Demonstrations, 101 
Detector, sterilizing, 137 
Diachylon plaster, 196 
Diagnosis, surgical, terms used 
in, 237 
Directory, 21 
Discipline, 104 
Disinfection, 117 
steam, 117 

Dislocation, congenital, of hip, 
339 

Lorenz operation for, 352 
Dissecting set, 267 
Distillation outfit, 141 
Doctors’ gowns, 226 
suits, 226 
“Dog,” 314 
Doors, 118 
Dorsal position, 44 
Dosage, hypodermic, method of 
computing, 211 



374 


INDEX 


Douche bags, 191 
Drainage, bladder, 68 
Drains, bismuth gauze, 186 
cigarette, 287 

Dress of circulating nurse, 29 
Dressing covers, 232 
rooms for orderlies, 157 
nurses’, 157 
sterilizer, 139, 146 
Dressings, 213 
gauze, 213 

sterilization of, theory of, 141 
Drip, Murphy, 67 
Drugs, asepsis of, preservation, 
210 

preservation of, 208 
valuable, safeguarding, 209 
Drums, 139 
Dusting, 23 
aristol on wound, 34 
Duties before operation, 73 
of circulating nurse, 23 

Ear, cotton applicators for, 219 
middle, ossicles of, removal, in¬ 
struments for, 271 
Economics, training, 225 
Economy, 102 
Ejector, 124 
Ekonome, 327 

Electric equipment, rules for 
keeping in order, 116 
Elevators, 125 
Emergency orders, 338 
sets, 306 

Emmett needles, 80 
Empyema, resection of rib in, in¬ 
struments for, 283 
Encephaloscopes, 273 
Enema, coffee, 323 
Gwathmey, 58 
saline, 323 


Engineer as instructor, 35, 142 
Enucleation of eye, instruments 
for, 277 
Ether cap, 51 
cones, 222 
Ethics, 161 
Exhaust fan, 134 
Eye, enucleation of, instruments 
for, 277 

foreign body in, removal, in¬ 
struments for, 276 
pads, gauze, 217 
room, 151 

toothpick applicators for, 219 

Fahrenheit thermometer, 205 
Fallopian tubes, test for patency, 
instruments for, 297 
Ferguson’s needles, 80 
Filiforms, 192 
Filters, 138 

Finish of operating room, 114 
Fire drills, 107 
First day, 17 
Fishhook, Lister’s, 80 
Fistula in ano, operation for, 
instruments for, 301 
Flannel masks, 234 
Flat-foot, 341 

adhesive plaster strapping for, 
351 

Floating bacteria, 167 
Flooring, 126 
Folding gowns, 236 
linen, 234 

Forceps sterilizer, 31 
Foreign body in eye, removal of, 
instruments for, 276 
Formaldehyd, 184 
Formalin, 185 

Fornices of vagina, packing, 217 
Fractional sterilization, 145 



INDEX 


375 


Fracture and orthopedic table, 
346, 347 

Fracture-box, 345 
Frontal sinus, infected, radical 
operation for, instruments for, 
273 

Fumigating cabinet, 193 
Fumigation, 118 
Funnel breast, 339 

Gag, mouth-, 50 
Gage, oxygen, 56 
Galen, 366 

Gall-bladder, position for opera¬ 
tions on, 46 
Gant pad, 215 

Gas-oxygen apparatus, Gwath- 
mey, 49 

Gastrectomy, instruments for, 
290 

Gastro-enterostomy forceps, 289 
instruments for, 290 
Gastrostomy, instruments for, 
290 

Gatch bed, 68 
Gauze drains, bismuth, 186 
dressings, 213 
mastoid tips, 215 
sponges, 213 
Genu valgum, 339 
varum, 339 

Germs, virulence of, 159 
Gigli saw, 268 
Glassware, care of, 194 
sterilization of, 145 
Glossary of terms, 239-257 
Gloves, rubber, 188 
mending of, 189 
to powder, 190 
sterilization of, 129, 145 
sterilizers, 141 
Glucose solution, 194 


Goiter, 64 
Gown covers, 231 
Gowns, doctors’, 226 
folding of, 236 
nurses’, 226 

Graduate nurses as anesthetists, 
54 

Grafting, skin-, instruments for, 
273 

Gram, 204 
Greeley units, 48 
Guy de Chauliac, 367 
Guy suture, 83 
Gwathmey enema, 58 
gas-oxygen apparatus, 49 

Hagedorn’s needles, 79 
Hallux valgus, 339 
varus, 339 

Hand lotion, hospital, 199 
Harrington’s solution, 186 
Harrison law, 59 
Head operations, instruments 
for, 267 

Health of pupils, 107 
Heat, sources of, 127 
Heating, 113 
Helmets, 227 

Hemorrhage, treatment for, 323 
Hemorrhoidectomy, instruments 
for, 299, 300 
Hernia knife, 294 
Herniotomy, instruments for, 294 
Hip, congenital dislocation, 339 
Lorenz operation for, 352 
disease, 339 

modified Buck’s extension 
for, 346 

Hippocrates, 365 
Holding retractors, 30 
Hooks and eyes, 195 
Hopper room, 155 



376 


INDEX 


Horsehair suture, 84 
Hospital Bureau of Standards 
and Supplies, 336 
cold cream, 199 
hand lotion, 199 

House, private, improvised op¬ 
erating room in, 357 
operation in, preparation of 
nurse for assisting at, 171 
Humidity, 135 
Hunter, 369 

Hypochlorite solution, 176 
Hypodermic dosage, method of 
computing, 211 
injection, 324 
Hypodermoclysis, 310 
Hysterectomy, instruments for, 
291 

Ideal surgeon, 365 
Idiosyncrasies, 175 
Improvised Kelly pad, 361 
Infections, prevention of, 104 
Infusion thermometer, 309 
Inspection, 105 
of instruments, 198 
Instrument cabinets, 125 
care-of, 196 
sterilizer, 138 
Instruments, care of, 196 
cleaning, 197 

for various operations, 267 
inspection of, 198 
scouring, 198 
selection of, 76 
sterilization of, 130 
Interrupted suture, 83 
Intestinal needles, 80 
curved, 80 
Mayo, 80 

Intravenous infusion, 307 
therapy, 323 


Iodoform packing, formulae for, 
177, 178 

Iridectomy, instruments for, 274 
Irrigating tank, 125 

Jugular vein, resection of, in¬ 
struments for, 272 
Jury mast, 344 

Kelly needles, 80 
pad, 35 

improvised, 361 
Kidney position, 44 
Kilogram, 204 
Kilometer, 202 
Knee-chest position, 45 
Knives, care of, 199 
Knock-knee, 339 
Kyphosis, 340 

Lane’s bone plates, 87 
Laparotomy, nurses’ scrub for, 
172 

sheets, 231 
suits, 228 
Lavage, 68 
Law, Harrison, 59 
Learning, 26 

Leg, amputation of, instruments 
for, 303 
rolls, 217 
Legal phases, 212 
Lembert suture, 83 
Lesson, model of, 109 
Lifting patients, 53 
Ligatures, 84 
Light, 114 
artificial, 115 
Linear measure, 201 
Linen, 27, 223 




INDEX 


377 


Linen bobbinette, 220 
chart, 224 
counting, 28 

estimation of stock required, 
223 

folding of, 234 
suture, 84 
washing of, 223 
Linoleum, 152 
Lister, 369 
Lister’s fishhook, 80 
Lithotomy position, 45 
Local anesthesia, 58 
Lordosis, 340 

Lorenz operation for congenital 
dislocation of hip, 352 
Lovell needle, 88 
Lubrication, 85 
Lumbar puncture, 319 
Lycopodium, 187 

Mannikin, 110 
Masks, 227 
chloroform, 63 
flannel, 234 
Mastoid dressing, 215 
tips, gauze, 215 

Mastoidotomy, instruments for, 
269 

Mayo’s double-ended gall-stone 
scoop, 288 

intestinal needles, 80 
needles, 80 
McDowell, 369 
Measure, cubic, 203 
linear, 201 
square, 202 
Measures, 226 
and weights, 184 
Meinecke infusion and irrigating 
thermometer, 309 
Menaces, 164 


Mending rubber gloves, 189 
Meter, 201 
Metric system, 201 
Michel’s suture clips and forceps, 
286 

Middle ear, ossicles of, removal, 
instruments for, 271 
Milliners’ needles, 80 
Minor rooms, 150 
work, 307 

Mobile operating unit, 357 
Model operating-room suite, 112 
Monel metal, 121 
Moral'responsibility, 210 
Morals of pupil, 21 
Mortise block, 91 
Movable tables, 47 
Mouth-gag, 50 
Mouth-pads, 227 
Murphy button, 91 
drip, 67 

Mushroom catheters, 192 
Muslin bandages, 220 

Narcosis, 61 

Narcotics, safeguarding, 209 
Nasal septum, submucous re¬ 
section, instruments for, 277 
Needles, 79 
blunt, 80 
Emmett, 80 
Ferguson’s, 80 
Hagedorn’s, 79 
intestinal, 80 
curved, 80 
Mayo, 80 
Kelly, 80 
Mayo, 80 
milliner’s, 80 
notes on, 80 
platinum, 79 



378 


INDEX 


Needles, slip-ons, 89 
surgeons’, 79 
testing, 8 
threading, 88 

Neosalvarsan, administration of, 
313 

Nephrectomy, instruments for, 
295 

Nephrotomy, instruments for, 
294 

Nicalloy, 121 
Nitrate of silver, 185 
Nomenclature of operations, 258 
Novice, surgeon’s relation to, 18 
Novocain, 60 
Nurse, anesthetic, 43 
circulating, 23 

duties of, in orthopedic sur¬ 
gery, 339 

graduate, as anesthetist, 54 
physical culture for, 160 
preparation of, for assisting at 
operation in private house, 

171 

to comprehend asepsis, 160 
pupil, as anesthetist, 55 
suture, 69 

Nurses’ dressing rooms, 157 
gowns, 226 

scrub for laparotomy, 172 
supplies for operation in private 
house, 362 
Nursing care, 101 

Oath of Hippocrates, 365 
One man appointments, 95 
Open air shaft, 135 
Operating suite, 112 
tables, 121 

Operations, nomenclature of, 258 
Orderlies, dressing rooms for, 
157 


Orthopedic surgery, duties of 
nurse in, 339 
tables, 346 

Ossicles of middle ear, removal of, 
instruments for, 271 
Osteoclast, 340 

Osteomyelitis, bone work in, in¬ 
struments for, 304 
Oxygen for stimulation, 55 

Packing, gauze, 217 
tubes, covers for, 231 
Pads, table, 122 
Pagenstecher suture, 84 
Pails, scrub, 125 
Para rubber, 187 
Paracentesis, abdominal, 325 
Paralysis, 102 
Par6, 368 

Passing instruments, 25 
Pasteur, 370 
Pathologic tissue, 237 
Patients, lifting, 53 

preparation of, for operation in 
private house, 364 
return of, to bed, 66 
rights of, 50 

Percentage solutions, 185 
Perineorrhaphy, instruments for, 
299 

Perspiration, wiping, 40 
Petticoated tube, 216 
Pharmacopoeia, 208 
United States, 208 
Pharyngeal abscess, incision of, 
instruments for, 280 
Phlebotomy, 316, 317 
Physical culture for nurses, 160 
Pin, 171 

Planning operating room, 111 
Plaster bandages, 347 
chiropodists’, 220 



INDEX 


379 


Plaster, diachylon, 196 
knife, 354 

Plaster-of-Paris cast, materials 
required, 349 
knife, 348 
saw, 348 
shears, 349 
Pledgets, aristol, 218 
Plumbing, 120 
Poisons, safeguarding, 209 
Position, dorsal, 44 
for gall-bladder operations, 46 
for operation, 44 
kidney, 44 
knee-chest, 45 
lithotomy, 45 
of operating room, 113 
pinioning children, 46 
Sims’, 44 
sitting, 46 
Trendelenburg, 45 
Potain’s aspirator, 283 
bottle for, 284 

Potassium permanganate, 118 
Pott’s disease, 340 
Preparedness, 106 
Preservation of drugs, 208 
of specimens, 193 
Printed codes, 143 
Private house, improvised oper¬ 
ating room in, 357 
Progress in methods, 20 
Prostatectomy, suprapubic, in¬ 
struments for, 303 
Psychology of training, 18 
Pulmotor, 62 
Puncture, lumbar, 319 
Pupil nurses as anesthetists, 55 
responsibility of, to surgeon, 
19 

Pupils, health of, 107 
morals of, 21 


Pupils, supplies made by, 78 
Purse-string suture, 83 

Quinin and urea hydrochlorid, 
60 

Radium, administration of, 322 
Receptacles, waste, 124 
Records, 76 
Recovery room, 66 
Rectal anesthesia, 58 
Regents, Board of, 72 
Regional anesthesia, 61 
Repairs, 104 

Resection of jugular vein, in¬ 
struments for, 272 
of rib in empyema, instru¬ 
ments for, 283 
Respiration, artificial, 321 
Responsibility, moral, 210 
Resuscitation, means of, 322 
Retention catheter, 192 
Retractors, cloth, 218, 220 
holding, 30 
gauze, 218 

Return of patient to bed, 66 
Rheostat, 116 

Rib, resection of, in empyema, 
instruments for, 283 
Richter needle-holder, 268 
Ringer’s stock salt solution, 186 
Room, eye, 151 
hopper, 155 

preparation of, for operation in 
private house, 357 
recovery, 66 
septic, 152 
sterilizing, 127 
tonsil, 151 

Rooms, dressing, for nurses, 157 
for orderlies, 157 
minor, 150 



380 


INDEX 


Rooms, store, 156 
Rotation of service, 17 
Rubber aprons, 191 
catheters, 191 
gloves, 188 
mending, 189 
to powder, 190 
spools, 187 
tissue, 187 
tubing, 187 

sterilization of, 145, 146 
Rubber-dam, 187 
Rubin’s technic for testing pa¬ 
tency of fallopian tubes, instru¬ 
ments for, 297 

Rules for scrubbing up and set¬ 
ting up, 74 
Running suture, 83 
Rust on white goods, removal, 
225 

Safeguarding narcotics, 209 
poisons, 209 
valuable drugs, 209 
Safety, barriers of, 161 
Saline, making, 180 
Salt solution, Ringer’s stock, 186 
sterilization of, 144 
Salvarsan, administration of, 313 
Sayre’s suspension apparatus, 
345 

Scoliosis, 341 
Scopic work, 151 
Scouring instruments, 198 
Scrub pails, 125 
Scrubbing up, 29, 172 
directions for, 172 
Scultetus binders, 228 
Self-reliance, 105 
Septic room, 152 
Serum, injection of, in spinal 
cord, 320 


Service, rotation of, 17 
Setting up, 30 

anesthetic room, 47 
Sheets, laparotomy, 231 
vaginal, 231 
Shields, 227 
Shock, 39 
Shoes, 174 
Signals, 122 
Silk catheters, 193 
sterilization of, 144 
surgeons’, 179 
suture, 83 

Silkworm-gut, 84, 179 
sterilization of, 144 
Silver leaf, 194 
nitrate, 99, 185 
Sims, 369 

cervix needles, 80 
position, 44 

Sinus, frontal, infected, opera¬ 
tion for, instruments for, 
273 

Sitting position, 46 

Size of operating room, 113 

Skeleton, 110 

Skin, preparation of, at opera¬ 
tion, 73 

Skin-grafting, instruments for, 
273 

Slip-on neeille, 89 
Soda bicarbonate solution, 194 
Solution, Harrington’s, 186 
Solutions, colors for, 184 
percentage, 185 
sterilization of, 145 
Sounds, care of, 197 
Specimens, 76 
preservation of, 193 
Spinal anesthesia, 57, 320 

cord, injection of, serum in, 
320 



INDEX 


381 


Spine, curvature of, 340, 341 
Splay foot, 339 
Sponges, 213 
counting, 41 
gauze, 213 
washing, 42 
Spores, 141 
Square measure, 202 
Stains, how to remove, 225 
State laws, 106 
Statistics, 107 
Steam disinfection, 117 
sterilization, 147 
Sterile adhesive, 194 
Sterilization, chemical, 127 
definition of, 127 
methods of, 127 
of basins, 145 
of bougies, 146 
of catheters, 145 
of dressings, theory of, 141 
of gloves, 129, 145 
of instruments, 130 
of rubber tubing, 145, 146 
of salt, 144 
of silk, 144 
of silkworm-gut, 144 
of solutions, 145 
of towels, 130 
of vaselin, 180, 199 
preparations before, 128 
steam, 147 
tests, 147 
thermal, 127 
Sterilizer detector, 137 
dressing, 139, 146 
forceps, 31 
glove, 141 
hot towel, 138 
instrument, 138 
utensil, 138 
water, 136 


Sterilizing room, 127 
equipment of, 136 
protection of, 128 
Stickers, tape, 221 
Stimulation, forms of, 323 
Stools, 122 
Store rooms, 156 
Stovain, 320 

Strabotomy, instruments for, 276 
Strapping, adhesive plaster, for 
flat-foot, 351 

Stretcher for use in private 
house, 361 

Stretchers, building, 28, 29 
Stump dressing, gauze, 217 
Submucous resection of nasal 
septum, instruments for, 277 
Suits, doctors’, 226 
laparotomy, 228 

Superintendent and operating- 
room, relations between, 327 
Supervisor, 92 

academic view, 108 
errors in appointments, 96 
model of lesson by, 109 
personality of, 97 
Supplies made by pupils, 78 
making of, 222 

Suprapubic prostatectomy, in¬ 
struments for, 303 
Surgeon, changes of, 76 
ideal, 365 

pupil’s responsibility to, 19 
relation of, to novice, 18 
Surgeons’ garments for operation 
in private house, 363 
needles, -79 
silk, 179 

Surgical code, 333 
diagnosis, terms used in, 237 
Suspensories, 228 
Sutures, 81 



INDEX 


382 


Sutures, buried, 83 
celloidin linen, 84 
continuous, 83 
Guy, 83 
horsehair, 84 
interrupted, 83 
Lembert, 83 
linen, 84 
materials for, 83 
nurse, 69 
Pagenstecher, 84 
pattern of, 83 
purse-string, 83 
running, 83 
silk, 83 

silkworm-gut, 84 
tables, 122 
tension, 83 

through-and-through, 83 
tier, 83 
Syringes, 196 

Tables, 46, 121 
combination, 47 
fixed, 46 

for operating in private house, 
358 

movable, 47 
operating, 121 
orthopedic, 346 
pads, 122 
suture, 122 
Talipes, 341 
equinus, 341 
planus, 341 
valgus, 339, 341 
varus, 341 

Tampon cannula, 216 
Tampons, 219 
Tank, irrigating, 125 
Tape stickers, 221 
T-binders, 221 


Teaching, 99 
anatomy, 100 
Technic, definition of, 170 
Telephone, 20 
Tension suture, 83 
Terms, glossary of, 239-257 
used in surgical diagnosis, 237 
Thermal sterilization, 127 
Thermometer, Fahrenheit, 205 
Thermometers, Centigrade, 205 
Thiersch’s solution, 177 
Through-and-through suture, 83 
Tier suture, 83 
Tongue clamp, 50 
Tonsil room, 151 
scrub, 172 

Tonsillectomy, instruments for, 
278 

Toothpick applicators for eye, 
219 

Touch not cases, 164 
Towels, sterilization of, 130 
Trachelorrhaphy, instruments 
for, 298 

Tracheotomy, instruments for, 
281 

tubes in situ, care of, 196 
Trade names, 337 
Trails, charts of, 162 
Training economics, 225 
psychology of, 18 
School Committee, 72 
Transfusion, blood, 312 
Transplantation, 353 
Trendelenburg position, 45 
Troy weight, 184 
Tubing, rubber, 187 
Tumors, 238 
Twigs, 38 

Unger’s method of blood trans¬ 
fusion, 313 



INDEX 


383 


United States Pharmacopoeia, 
208 

Urethrotomy, instruments for, 
302 

Urine, 52 

Utensils, care of, 27 
sterilizer, 138 

Vacuum, 140 

Vagina, fornices of, packing, 217 
Vaginal sheets, 231 
Vaselin, 180 

sterilization of, 199 
Venesection, 316 

Verbs, special, relating to operat¬ 
ing, 265 
Vesalius, 368 
Virulence of germs, 159 
Viscera forceps, 286 
Volatility, 208 


Volume, metric, 203 
Vulsellum forceps, 292 

Washing linen, 223 
sponges, 42 

Waste receptacles, 124 
Water sterilizers, 136 
Wax, bone, 179 
Weight, 204 

Weights and measures, 484 
Whisky, 337 
Whistle cannula, 216 
Whiteness of linen, 223 
Wick, 220 

Wiping perspiration, 40 
Wisdom in buying, 103 
Workroom, 152 
management of, 154 

Zeiss light, 116 









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